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r APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 o- (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED w IaI 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 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADpRESS10R All CITY G PARCEL S1ZEIAPN#3'O -335- OWNER'S I 3 2" 5 OWNER'S NAME ADDRESS tL goo PHONEf 6$-yyI aa CONTRACTOR ADDRESS 1-2606t ol/1�ZS OQES�iJCN DSO( PHONE Z �'ZZZI SUB CONTRACTO - "' - AD 86 CN L" PHONE TYPE OF WELL1FUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL i ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J New❑Raaf, H.P. DEPTH PUMP SET FT. [TYPE OF PUMP) FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING�, B �PESTRUCTION: ^� z INTENDED USE TYPE OF WELL CONSTRUC710N SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM❑ DIAOF WELL EXCAVATION A DIA.OF CONDUCTOR CASING D D Buck C/PWVATE 13 .GRAVEL PACKlSIZE TYPE OF CASINGISTEELIPVC DIA,OF WELL CASING 13 O PUBLICAMUNICIPAL 13 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ,P IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED SY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED; ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yaa ❑Ne S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S Y PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER ' 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:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF f CALIFORNIA," THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12041 4484423. COMPLETE DRAWING AT LOWER AREA PROVIDED. (] Signed X r Title, Py _ Lgg is .,.. .a. I ! PLOT PLAN(Draw to scale)leY S570 ` 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, �TTTTT^'''' 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. 1 HAZELTON AVENUE Mws co in Mwl R yew t 9 L' Ff}RhdER + z Lw EXCAVATION NWa O Z MM2 RAMP TRUCK TERMINAL _ r � W _ W 0.' IJ1 Z w DEPARTMENT USE ONLY Applioetion Aooepted By . 2 3 .._..._.... Date ! A,oa Grout Inspection BY Date Pump Impectlon By Dote Destruction Inspectlon 8y Date Commenb: �..�f��J ..,V 4�.7 9�G ... ,•. t ACCOUNTING ONLY: AID# FAC# i PE CODES FEE INFO AMOUNT REMITTED CHECK#fCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 350 23 . I Rte. F ,I r 4 { F