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APPLICATION POR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 95201.368 {209) 468.3420 NON-REFUNDABLE PERMIT(EXPIRES i YEAR FROM DATE ISSUED (C9nli in Triplicate) ' APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED,THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SA ADUlN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# �,� ✓C //1a CITY PARCEL SIZEIAP'N# .H. OWNER'S NAME AIDDRES9 ONEC�("�' CONTRACTOR ADDRESS _l 'S „PHONE $us cONTRAcrOR / aoDRE`ss 3z ^7 PHONE�E TYPE OF WELLIPUMP: IJ NEW WELL ❑ REPLACEMENT WELL laMONITORINO WELL 1,e j:1,1fj/� ❑ OTHER , 13 INSTALLATION 11 WELL SYSTEM REPAIR ❑ C IROl CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑Nm©Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL . (TYPE OF PUMP) 4 O ❑ OUT-Of-SER CE WELL 11 OEOPHYSICAL WELL# ❑ SOIL BORING �STRUCTION: 1 %` �S ��• ` ` , - ( INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DlA.of WELL EXCI. AVATION x A DIA.OF CONDUCTOR CASINO b ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE % TYPE OF CASINGISTEEUPVC DIA.OF WELL CASINO 11 1 f7 © PUBLIC/MVNICIPAL 13 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONlAq ❑OTHER 1` GROUT BRAND NAME p I _ GROUT SEAL INSTALLED BY ❑ MOHROfpNG GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee [IN. S, APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 3 PROPOSED CONSTRUCTIOUMMIL IND METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND ! REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE Of THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR 8UB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH,THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' HE APPLICAN MUST CALL 24 HOURS IN ADVANCE FOR ALL REGURED INSpECTWN6 AT(2pe} JT422. COM E DRAWL GAT LOWER AREA PROVID c Signed X l -_ Title Q ♦- ' Data I r r PLOT Pl.Arl form to 8ealal Scale � �'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.* STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, y . .......,,-_ ..,.... ........ ........... 4 .,.,.. -. - .,. ..:.,.. -. r .. '.. ' >... i.. ... . . ...... - ' i _... . _.. ..... ................. . ' G .. .. . .. � r . f �ra- .... .... ........................ ......:.. . .... : I DEPARTMENT USE ONLY APPflesticn Accepted BY_- _,....r •L--.✓' Ares '. Great Inspection By Date Pump Inspection By 't Date f Destruction Inspection By Date i Commenty ' ACCOUNTING ONLY; AID# FAC#( PE CODES FEE INFO AMOUNT REMITTED CHECK+IICASH RECEIVED BY GATE PERMITISE MCE REQUEST NUMBER INVOICE '