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APPLICATION FOR WELLIPUMP PERMIT JOAN JOAQUIN COUNTY PUBLIC HEALTH SERVI, ENVIRONMENTAL HEALTH DIVISION- P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 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 TITLE,CHAPTER 9-11 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN#_20 72 W t L�m Iy' I-\V n n/ f,—CITY_ Ij'� ,((I PARCEL SIZE/APNX OWNER'S NAME 20 72 1/Y. V6 l f`�m I W, Ak/lo rl U t� ADDRESS PHONE N CONTRACTOR �1E(� A, ,��I y_� ADDRESSr6n uc# PHONEXq-Cz� �4 SUB CONTRACTOR1Jel 'o RESS _/`k PHONEM / 7J TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# (TYPE OF PUMP) ❑New EIRepair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 C ❑ OUT-OF-SERVICE WELL C3GEOPHYSICAL WELL X SOIL BORING B r 11 DESTRUCTION- to INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING NIA D c ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC N1 DIA.OF WELL CASING N J ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ SPECIFICATION SPECIFICATION nn R 13IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Sf�/ GROUT BRAND NAME—6�(/�t1 t� l�('1�1 E ❑ MONITORING GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes ❑No S r APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER � CABLE OTHER � j I HE9EBY 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 C 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 II 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 WORM.FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE AP L)CANT MUST CALL 4 HOURS IN ADVANCE FOR ALL REQUIRED DIINSPECTIONS AT(/2/009)4� 7� 68g3423. COMPLETE DRAWING AT LOWER AREA PROVI ED. Signed X �� (� Title_L/'U��=L-1—Al r7,, 3-Z; Data PLOT PLAN (Dr"v to Scale)Scale 'to 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. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 5. 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. .. ... ..:...._ _ ....... .. .. .. ..�0 .;.....: .. ..... ..:.. . . .. ..... ...,.. .'.... ..... .... ... .. .. DEPARTMENT USE ONLY Application Accepted By r1�wA_A�.�. yQ� Data Z' '�' S Area -14-).q C Grout Inspection By �r `+��-- 'li-�Lti Date` l/ tPump Inspection By Date 1 Destruction Inspection By Date `( C Comments: L"{L Cif C (�L I �1 Vv ' I�-q '( ACCOUNTING ONLY: AID# FAC# AE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 0 3 6U 1� 0 of