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APPLICATION FOR WELLIPUMP PERMIT` SAN JOAQUIN COUNTY PUBLIC HEALTH SEr�AS ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 469.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {ComPloth In TrWieattel JOAQUIN COUNTY APPLICATION N HERE EL MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18�MADE IN COMPLIANCE WITH SAN TY DEVELOP/MENT TITLE,C�HA•PTER 9-11 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC_HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. �!�I { f�r N Ftot!�� CITY cr N JOB ADbRE8S/0R API# 6 J 7 PARCEL SIZEIAPN! OWNER'S NAME k /' N f /I ADDRESS f�N! /'�h/� �r .r PHONE# at I CONTRACTOR, ,./�JY', r F./��q. ADORE SB t D l.t �!� J PHO, SUB CONTRACTOR ADORE +0I DDDIfl��.1PPPP5�SdBBBB PHONE I O�- 2 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ' S r7 ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL it 1 ❑New❑Repair H.P. I; i � y ITYPE OF PUMP/ DEPTH PUMP SET FT- 1� FIRST WATER LEVEL f ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 0 ❑ 80'IL BORING B y ❑DESTRUCTIONr INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM 'j A DIA.OF WELL EXCAVATION j. DIA.OF CONDUCTOR CASING p I ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CA81N0lSTEELIPVC DIA.OF.WELL CASINO p ❑ PUBLIClMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E i ❑ MOHTrORING GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes ❑No S, i APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S F PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE '_OTHER------------ —�� I 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 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 IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TYPE FOLLOWINO: 'I CERTIFY THAT IN"THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMrr IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNI T APPLICANT MUST CALL 24 NO IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001408-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. ,ry / Signed X .. _ Title Date PLOT PLAN(Draw to S"ol Salle 'to ,j 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, f 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED x 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. L I E T fff DEPARTMENT USE ONLY i Application Accepted By Data ,' Area ' Grout Inspeetlen By Date Pump Inspection By 'j Date Destruction Inspection By 1 Date y, Comments: f .I { i f ACCOUNTING ONLY: AID# PAC# - -i, p PE CODES FEE INFO AMOUNT AEPPTTED CHECK/!CASH RECEIVED BY DATE PERMITISIERVICE REQUEST NUMBER '' INVOICE