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APPLdCATIOil FOR WELLIPUMP PERM( \er SAN JOAQUIN COUNTY PUBLIC HEALTH SEftES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201.988 (209) 460.3420 NON-REFURDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (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 TI,TttE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN! J G-�'j" O�.[.IZ.< �Q{,„[,(�{i CITY ii:::t&(,41'Gy P RICEI,�IZE17NN#/ q OWNER'S NAME 0 d Lt OL-. ADDRESS /d).Z.O�,Gt! _�I J C 479 PHONE! 2 1.97 -771 CONTRACTOR �Q✓' L' ADDRESS J WO uutyl YL PHONE#YL-3717.3/0 ADDRESS BUS CONTRACTOR r / W� Oa LIC! / PHONE!94ZZj -LW TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL! ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! El ❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) �y /` 11OUT-OF-SERVICE WELL 11GEOPHYSICAL WELL! 1/Y601L BORING 1-1 S a 11 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION&. A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION (!n DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STE"VC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BYGROUT BRAND NAME !^ of �.7'�E ❑ MONITORING GROUT SEAL PUMPED: 11 Y.. ❑N CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S APPROX.DEPTH . LOCKING CHESTER BOX/STOVE PIPES S PROPOSED CONSTRUCTRONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER (— /4• I HEREBY CERTIFY THAT 1 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 JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT ON 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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&.COMPENSATION LAWS OF CALIFORNIA.' E APHI T MUST CALL 24 HOU4RS M ADVANCG.FON ALL"IFOi AED Jh*1`/,C,OWN&AT t/too s)4*11,%4p. COMPLETE DRAWING AT LOWER AREA PROM�JiEp, Q Stoned X_t r. avL../ � �.L� „_- Title �l�L ' " "S..f�`� l Date S� F PLOT PLAN(Drew to Scale)Seale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, !. 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 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. DEPARTMENT USE ONLY p 49�Applleatlon Accepted By _ _,._._Dot e _Area Grout InoWtion By_ Date Pump Inspection By Date f Deetruetion Inspeetlon By ��/p� Date Comments: /WV-a[, ACCOUNTING ONLY: AID! FAC! PE CODES FEE INFO AMOUNT REMITTED C"EC&CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE �Ol Iris-- 17 Z-5 1