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APPLICATION FOR WELIJPUMP PERMIT ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOK 388, 445 N. SAN JOAOUIN ST, STOCKTON, CA 95201-388 (209) 460-3420 MOM-REFUNDABLE PERMIT EXPIRES i YEAR FROM DAYS ISSUED II I' ICemplea in Trip iwte} APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIO INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN 1. JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPT4ER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APIC_ c� 1.[AD Uk1 t IM� nye CITY PARCEL SIZEJAPNR M i 1� Ma r OWNER'S NAME _ _ � _.. ADbRESS 1'1 U.�i Y"DV PHONE#101 I+-s cI a�. i u l- +i. q4 7Z;7W CONTRACTOR • ADDRESS !!CI PHONE/� OUR CONTRACTOR ADDRESS L1CRt PHONE! II TYPE.OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING LLf ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS�CONNE T REPAIR ❑ VAPOR EXTRACTION WELL! ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL {TYPE OF PUMPI pf ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL NELL# I SOIL BOWNq g ❑DESTRUCTION: l I h INTFT7Dm URE TYPE OF WELL CONSTRUCTION SPECIFCATIO e A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING I� D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELJPVC DIA OF WELL CASING II O ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION Iy� ❑ IRRIGATKINIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME I! F ❑ MONITORING GROUT SEAL PUMPED: ❑Yoe ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea []No s APPROX.DEPTH—- - 4. LOCKING CHESTER BOXISTOVE PIPE II s PROPOSED CGNaTRUCTIONIDNWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER ��r li. I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN A-CORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,ANDIRULES AND REGULATIONS OF SAN JOAQUIN COUNTY. HOM ER pR LICENSED AGENT'S SIGNATURE CERTI IES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK'fFOR WHICH THIS P:RMIT I81 I SHALL NOT EMPLOY PE RSO SUBJECT T W ONAN'8 COMPENSATION EA OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWIN "I C RTIFY THAT IN THE PE CE FO H THIS PERMIT 181 SUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-A COMPEUATION LAWS OF CALIFORNIA." FIE CANT MUST CALL 24 ALL REQUIRED INSPECTIONS A (20614!83423. COMPLETE DRAWING AT LOWER AREA PRO D. i Stone I 4=1 t TIUa R T Dae G RAT PLAN(Draw to Scale)Scale_ 7. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PRO.I SED 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 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. I� ;.....- ....... ............ - �ldi� y. .. . .. .. : Pu .....: " �slawl a. �Iro'� I. I : I -..... ..... . ... - ... .. . -. .. �� ... . . I :I ... ..... ILI ..... .... ... ... i'...... ........ ........'.. i DEPARTMENT USE O LY r AppllaHon Aooepted BY Date .{ Area p r_ Oreul Inspection BY.-:a`;- —�.,_.-..�"'-:•'•--�='.: ---..—._-.-Date. •.- ••.�"=---Pump Inpeetlsn�B —^-�- - ' - '--" - Date-. O.etnntlen Inspection By Dae II Commenu: 11 M �s ACCOUNTING ONLY: AID! FACT `I PE CODES FEE INFO AMOUNT REMITTED CH K.T ABH RECEFVE�BY AT PE3RMITISE RVICE REQUEST NUMBER INVOICE ill o r 7 G P I� 9 .II. I' F I .I 1