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APPLICATION FOR WELLIPUMP PERMI' SAN JOAQUIN COUNTY PUBLIC HEALTH SEh .ES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201.988 (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 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI�NiY rl�-'1 .i,K.;� f, I, • - j„ 'I. r 11� l'FY �•Lr�--l.It}i+v1^� PARCEL 31Z APN /�'L•`��fp'2'f T' OWN R'SN ME(Ii1%CtiN I] tl.,tiO.,.1 C• \i(.ti.:Nr4C(v�11.�['C()ADDRESS IJJ•L-t'�c-,� �m�� PHONE CO r\SA �— ADDRESS + C �c�4� I;c�- Z«� UCI PHONE A16 k-f' �e�1l � i -9MCONTRACTOR t<Z I�iJ+1�✓L�-Y r+�,L{/�(1r�yfi�IrllrNr. Q1, ADDRESSI .'`f- -a. UCIC,7 T y+'t�lt h PHONE A;0'C , ` TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ 'El OTHER 121.b ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACT ON WELLI J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ""Ct'S O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL R pGL SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION — 7 r DIA.OF CONDUCTOR CASING //1% D 11DOMESTIC/PRIVATE 11 GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC ti A DIA.OF WELL CASING A11AQ 11PUBLIC/MUNICIPAL 11DRIVEN DEPTH OF GROUT SEAL I..fail JET f SPECIFICATION j"!A- R F""❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY--i2 'r+rR��Ji((1,1 GROUT BRAND NAME TFL.'I Iy111.1, �t ❑ MONITORING GROUT SEAL PUMPED: [aY. [IN. J CONCRETE PEDESTAL BY DRILLER:[1Y" ONo S APPROX.DEPTH I / LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 3e°C• •--:41W- I HEREBY 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. HOVE OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPUPAW MT-gn— CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091442-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X_>1 i'/ - fly Lat,L. I Title� .cam.-(.�*i �Jr Data PLOT PLAN (Draw to Scale)Sulo I 'to r`'`- i'�'.• �Z.. 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 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. ow.4r, Rd• . . .. . 1 i _ ..: tL ail \.: .. : _:. .... _. . _. r n�Cake t DEPARTMENT USE ONLY t Application Accepted By r Date I �" Area Grout Impaction By _ Data Pump Inspectlon By Date Destrmtlon Inspection By ^V Date 111 Comments. ACCOUNTING ONLY: AID# FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DA E PMMIT/SERVICE REQUEST NUMBER INVOICE