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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES HEALTH DIVISIN P 0 BOX 388, 446 VN. SAN JOAAQUIN ST., STOCKTON, CA 96201.388 ,•'�)!A it ti (209) 468-3420 rrII // SL � � NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE I "ii&,CT 3 Ppb !try (Complete in Triplicate) J 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 JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. � JOB ADDRESS/OR APN. /I'Lr 1 Ni�.f-;IrG� I%�:/�\ [\�)CI'�'I CITY � �I nal I'-JF� PARCEL SIZE/APNN 1_ 9`.)L-"�,)7✓/11 / y 7 OWNER'S NAME Sr t:•'GU�l ( / , �( �a " 51•�� 9 ,.5 v G'1-C, ADDRESS/'S' I`- /,// Ilk ln-k t,rj�f*l'/��-l/\SF t�7 PHONE✓�/ !�I_��/� CONTRACTOR. /SSI * ,-4 ., I !� �� (� ^ ADDRESS �'I'�/- v 4 A,IV,il,6//_+."'CIC# �}-, V PHONE N1 SUB CONTRACTOR ti)/I//�- f Ei"(.'� i2 4(4 �! '�'t�Y /+-P IC��' ADORESII��t'" it�� i r;.(;. K �r f�7n C CJ7.7 PHO E i�f�, Lf TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL. J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) /� ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING / f ��1r } g C3 DESTRUCTION- y 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/STEELJPVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION 17 ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLFR:❑Yes ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY _AUGER CABLE OTHER 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. 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,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CA 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)4&83423..COMPLETE DRAWING AT LOWER AREA PROVIDED. Sipped X '1'itla_ w�n /P �f Y 1� � Data v OT PLAN(Draw 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. CUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. CIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. S-RUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. . . . . z m g a s w z z N00 4 a' s _ Q� dd O a z O a s ..... mJ Gi + h N O Z Z -wS0 Z C5 ♦ �® ® ir0oz o w cal 0 O ® o j C7 N F (^ ry �® ® to + + W o% j x + b - --�- � w \ OVOH NOLNNONY z W o 61 z o lo a o o p _ o , �+ n tl lllrvnN �I® + n L. ... .. ...... dV-9df-b6 �Nimrea Q " . DEPARTMENT USE ONLY ApPlicatlon Accepted By / 1 -- Date D'-2I y`+' Aree Grout Inspection By Date Pump inspection By Date Dent—tion it p�ectiioo'n By�O y�j, ,/I (�✓- Date Comments: T-'f f5 t TLS �. w o 1 !"z flbs 1 -Fy r 2-(-0$D-m orn.to o . vI Lv P fl to ACCOUNTING ONLY: AID# FAC. PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE o 1a�5 {hQ �b31 o�16 L4 2