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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 _ ;+'1��` '��-�f) (209) 468.3420 "E R"`-'E NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEb MAp —S PH 1 : 07 (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 DEVELOPME+NTT�TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COLINTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# I-l/" ✓7 �L^1�l V C�C-[�� 11.0,7 CI CITY J � I�.1{�(L PARCEL SIZE/APNX OWNER'S NAME + 7 / �5 1 L_+L I�(`L7JZ/� '��^ ADDRESS2-&, )q _� 5J' l\_` + T/I/y�(,� I a y L .[)�Y�1/ �/��S (. /iw`IFHONE N C -7�) CONTRACTOR S 'e•C Y_' �i'�'' ADDRESff C I ,.�CL tiles QI�I V'G /a ILC fJO� �J U PFiONEx,( -�/7`ZZZ� _ /y/7,,}� T SUB CONTRACTOR ADDII Z' Z �L(� U �` t IAONR.L 3 -�C( 7) � 7 TYPE OF WELUPUMP: NEW WELL ❑ REPLACEMENT WELL [ MONITORING WELL 1—'z Z ❑ 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 B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS P": /"t,+1v 71 2 r��{Y 7/ A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION `-�►'„I ,T 7- DIA.OF CONDUCTOR CASING fQ D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING2'1 q IIS 1 +d Ce. D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL I ,' CIFICATION l .? p❑ IRRIGATION/AG OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E W MONITORING 2 J GROUT SEAL PUMPED: ❑Yea [IN. CONCRETE PEDESTAL BY DRILLFR:g Yea ❑No S APPROX.DEPTH__j, — '-"� +Y LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRI LUNO 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'S COMPENSATION LAWS OF CALIFORNIA." THE APPLIC NT URS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)4653423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Shred x ]_: .��1' 2 Titl /!r/!G%'f ✓✓�l/'Q Dae PLOT PLAN(Draw to Scala)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 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. I I Post-it` Fax Note 76711 Date TT, f 1 ► u From Co./Dept. Co. V N w Phone# Phone# m .......:......:.. a Fax#� Fax# m . .:......:.....<......:..... ru ` :.......................:,.. Q* A w 8.a ......;............. e ° I v .p......:...... y$'( $.F OF .. o yy44- g yy44 �%yc= T ............. C d2 42 W2 LL ..... ...:...............:......:..... n �. A. VY N ......:.......:.....:... TI , `l'(4��_�]p�/yy\�"t DEPARTMENT USE ONLY '�j Application Accepted By +" 1�A1W+'��I Date -/" S �� Area Grout Impaction By Date Pump inspection By Data Destruction Impaction By Data - y" Comm—w / �. 'W -� ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE