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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SEI. :S ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388, 304 EAST WEBER AVENUE, 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 I6 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# -� V!� .L A PJi �� CITY PARCEL SIZE/APN# �/` r ` 1 CID OWNER'S NAME 1 t(k t 4w !� {i f.f� ADDRESS ) 4 -�IAM" PHONE I• %� CONTRACTOR ADDRESS 4) LIC# '/r ig- �) PHONE I SUB CONTRACTOR ADDRESS LIQ► PHONE# TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR El ,/ VAPOR EXTRACTION WELL r ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑.OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING ♦ D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 4 SPECIFICATION ., �iV f �. ff R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY T 'Ak GROUT BRAND NAME {`�'-�I �I' E ❑ MONITORING ��'(•rGf �,L V` �,�1� GROUT SEAL PUMPED: ❑Yea [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No S APPROX.DEPTH 55 "t t"E,Y LOCKING CHESTER BOX/STOVE PIPE g PROPOSED CONSTRUCTIONIDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 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 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 SUB-CONTRACTING 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.* THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1200)4a*3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Tltlb Data ��L7 0 PLOT PIAN (Draw to Scale)Scala '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 6. 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. ...r t. -A4+&0- J r F `` i ,.t y PU;ir,J (t"ZtS:4�'�Trf. f�UG.�g AJ a PAYME.NT- __:.. ... . ,lAld 2, 5 f ,.., ... :. .__ ..; SAN J(UNQWN:CUUNiI: PUEtIJC HEALTH.SEtVfY'.eS �N1lIRQNMSWAL HLEALTH CMgio-, 9 - - r DEPARTMENT USE ONLY J fI Appllcetlon Accepted By Date ! �'/ Area Grout I-pectlon By Date Pump Inspeatlon By Data Deattm lon Inspection By Data Comments: �+t.�.( ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE