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APPLICATION FOR WELL)PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 (209) 468-3420 11401111-REFUNDABLE PERMIT EXPIRES 9 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/9-111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC PrUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNK -' ll�J(..� /�L)�J,t.frJ(n. t, �i Lam( CITY Iff�'U..�rC� IL��^ �f s ) PARCEL SIZE/APNK""')l—�J��T / J OWNER'S NAME /j r ll IAG1 Lj /)�{,��4�d' �1 ADDRESS { V / G L.1� ttJ PHONE# CONTRACTOR-5,-11ti. d'ti '4! O 1. ADDRESS 4 'I 1" -4}r'I LI X a PFi 0NE#2L"1 Ic- 1k.S 1�G v� 1r�,-,v SUB CONTRACTOR �•y „'/;�C,r1,�Lr��,Q2-�4�I.UICci f F C'�Y�i- J^Uij ADDRESSI l .) -I!E.j.`,rj��;7tY,l�� JCK-z� PHONE K��^' TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL K J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ,�/ 7,r ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL K IL7 SOIL BORING ` B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: C1Yes C1No CONCRETE PEDESTAL BY DRILLER:❑Yes ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE _ { S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER U.�,� f p"` I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)4883423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Sipr»d X Title /] M to G.-(/L� Data L PLOT PLAN IDraw 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. MMENSIONED 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. rc z z 0 L' s 5o n a w Q• QQ _ /® w K m 0 Q w000 vi ISI I L 0 + j o S a L z Y 0 \ OV08 NOIN80111 w - Z P a16 o z c� m + ZV-9ZC-b6 atnrvnn I �— UNIMVNU DEPARTMENT USE ONLY Appli:anon Accepted By - Data /�' %�l'-�`� Area Grow impaction By Date Pump Inspection By Date_ Dmtniction Iropection By - Det. Comments: ACCOUNTING ONLY: AID# PAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE -,Cn' �.L j D:2�-�" 1 i DRIP