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APPLICATION FOR WEL'LIPUMP PERM" SAN JOAQUIN COUNTY PUBLIC HEALTH SEES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9MI388 (209) 466.3420 ' I F NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; f6mplit6 In TTipIluts) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN ; JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 1 1 S,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEB,ENVIRONMENTAL HEALTH DIVISION. - JOB AODRESSIOR APNrU Z2 0 kj /� I p4 CITY :/32-dt-a, PARCEL elZE/APN# OWNER'S NAME �" [�' d1 �, ADDRESS ON CONTRACTOR - ~ thADDRES6 r- - /YOU CH# P=Er &4/ 137Z�7�7 SUB CONTRACTOR V{J ` ADDRESS G 0/PHONE i'// d TYPE OF WELLIPUMP: ❑ 13 RE NEW WELL FLMfNT ACEWELL —mo� ` MONRORING WELL# - � ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR 11�❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O !TYPE OF PUMP! ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING R STRUCTtON; J312Gr v AAL 442 INTENDED USE TYPE OF WELL t CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL:EXCAVATION DIA.OF IONOUCTOR CASING ❑ DOMESTr-mmVATE ❑GRAVEL PACKIBIZE TYPE OF CASINGMTEELIPVC DIA.OF WELL CASING O ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAO 13 OTHER ' GROUT SEAL INSTALLED BY GROUT BRAND NAME .E 11 MOkTIOPoNG GROUT SEAL PUMPED: Ely. ❑Ne CONCRETE PEDESTAL BY DRILLER:[3Y" ❑No S APPROX.DEPTH LOCKING CHESTER SOXISIOVE PIPE - S i PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY 1 AUGER CABLE OTHER IF I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND r REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,i SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH,THISPEKMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' E APPLICANT UST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRE'a INSMTRINS AT f206144111114422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X 4 - GI�.<< TRIP _ j PLOT PLAN(Draw to Scale)Salle � '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 i E. 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, F - t _.[ .....:. :. . . f .. ..... ......... . I .; f ........ ...., .. - _- - .. .. .. .. i ..'.......:, : . ....:.... - - ., .. .. ., ., ., . - - i z DEPARTMENT USE ONLY / APPlketlon Aaaepted BY pale D VArm o Z., } Oreut Inspaction By Date "Pump Inspection By Data , Deetruatlon Inspection By il, bete Comments: i, ACCOI NT1NO ONLY: AID# IFAC#i r PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 502 690 •ZS T4 0