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APPLICATION FOR WELLJPUMP PERMIT r" z1��'AN JOAQUIN COUNTY PUBLIC HEALTH SERV;1, _ •--9 e ENVIRONMENTAL HEALTH DIVISION l P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 488.3420 { I NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1i (Complete in Triplicate) 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, 'C/H`p�P,�/ER 9-1115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. I JOB ADDRESSIOR APN# d>`I ;^�Y VV d4-, ��s CITY �1 617 PARCEL SIZEIAPN# OWNER'S NAME Clps� ,�- �. (�•{ Or) F,� T• ADDRESS g`itlri^I/��/1¢� 76'3J(,067 PHONE T /f/p I CONTRACTOR�C�r WC -J!,r rVV �i�"&- ADDRESS I1�7 4 l�ii''1-by, sti, � 1 }_..� ,• Fig 049,Y 1 IJC# -y e- PHONE#5'19337 X73% SUB CONTRACTOR 1 'Ir1 1 I [r 1r<• ADDRESS 1 ig.vD( 4Z J '1[' (j LIC# I / PHONE# _ _ JSYf• Q r% _ TYPE OF WELLIPI1MP: I�NEW WELL ❑ REPLACEMENT WELL MONITORING WELL# 3 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 O (TYPE OF PUMP) l ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: p INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSA q, 11 INDUSTRIAL v ❑OPEN BOTTOM DIA.OF WELL EXCAVATION S in eA-,-� DIA.OF CONDUCTOR CASING ,D 11 DOMESTIC/PRIVATE IGRAVEL PACKISIZE TYPE OF CASING/STEELV IPVC j+ L- _ DIA,OF WELL CASING p ! ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL___ SPECIFICATION 1501 i ,/ ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY -r GROUT BRAND NAME Q G[. Q E_Lfk �) 9MONITORING GROUT SEAL PUMPED: ❑Yes a CONCRETE PEDESTAL BY DRILLER:PfYee ❑No $ APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE g, PROPOSED CONSTRUCTIONIDRILIJNO METHOD: MUD ROTARY AIR ROTARY AUGER��CABLE OTHER 3 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 WORK 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 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 CALIFORNIA.' T PLICANT MUST CALL 2414OURS_ff ADVANCE FOR Akk REQUIRED INSPECTIONS AT 1209)4083423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SlpnedX - _ Title Data S` PLOT PLAN IOraw to Soelel Sub 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. I 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. 1 STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. _ >_ ... . _ .. ... ..... ......... - -- - I DEPARTMENT USE ONLY Application Accepted By �iF-uy•-C2oWff Date 'L 5 � Area f Grout Inspection By Date Pump Inspection By Date Destruction inspection BY Date Comments: f � V v. 5 ACCOUNTING ONLY: AID# - FAC# I r ' PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITISEAVICE REQUEST NUMBER INVOICE 3541i sike00s33z: