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"_ APPLICATION FOR WELLIPUMP PERMIT r �. N JOAQUIN COUNTY PUBLIC HEALTH SERVIL, ENVIRONMENTAL HEALTH DIVISION P 0 BOX 3B8, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96209.388 (2091468-3420 MON-REFUNDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Trolkatel 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 COMPIJANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE-CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSOR APIA' PM/ 7 W pfy -3 r CITY r PARCEL SIZEIAPNi' OWNER'S NAME n j�— �' _ r ADDRESS PHONE/10.7 J CONTRACTOR./\(I RESS HE JJI SUB CONTRACTOR ADDRESS UCA PHONE A + 'TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLrr ❑ OTHER fl}� '�❑-.+IN�TAL.LATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL A .! 00 NeW 11 Repair H.P. ` DEPTH PUMP SET�FT. FIRST WATER LEVEL ?1 ' ' O (TYPE OF PUMP) /` ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL r ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTFUAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DiA-OF CONDUCTOR CASING p DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEEUPVC DIA_OF WELL CASING D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRPJGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E I ❑ MONITORING GROUT SEAL PUMPED: ❑Ye. ❑No CONCRETE PEDESTAL BY DRILLER:Ely. ❑No 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE 5 PROPOSED CONSTRUCTION/OPoLLJNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER- .-I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH CAN 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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS RMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'a COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 ItOURS IN ADVANCE FOR ALL REQUIRED INS TIONA AT 1209)4603423. COMPLETE DRAWING AT LOWER AREA PROM D. Signed T O.t. PLOT PLAN IDr.W to Sc.W.l Sc�l* 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOC ON OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.QMNG DIMENSIONS AND NORTH DIRECTION. - EXPANWN 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. -. .. ... __ ... 1 c�� .. V .. MAY 18... 9.° ... ....' u .. ... ....... .... . .:.. SAN JOAU'ui qi C,Q�sJF�T'Y PUBLIC HEALTH-SERVICES _ ..... - . .,..... .. ... 44 F ENVIRONMENTAL HEALTH DIVISION, .....: .. _. ......