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APPLICATION FOR WELLIPUMP PERMIT D gl � � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �'' ENVIRONMENTAL HEALTH DIVISION J U L 2 8 jggr, P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 468.3420 _NVIRONMENTAL HEALTH NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED PGRM!T/SFRV!CEQ (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 1OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR A/PNN# 13751 �• W I(1QVJ (j I"UOQ.IQ CITY U IS�G+IC.L" n PARCEL SIZE/APN* OWNER'S NAME /"1('_ C4 v�� •'ICS. DNQ V'LQ,IQ 2e-1\Z('ADDRESS ZS6L4 W.�-J";Cn` „d., s 40��Jh PHONE+7 CONTRACTOR S�,,A\�y L�V�r c)vACw�,t..,. ►1 I�1-."QI GSC QS ADDRESS \1\O N`10,k" 53. 8PC-01.0" LIC# PHONE N 2 SbQQ7G SUBCONTRACTOR QI` �Q-rrq�✓� LYQ 11"L13— 0r1)I1t10 ADDRESS�Q VZ-�u P�h4U+G��LJC#yj,K-�-6_PHONE TYPE OF WELL/PUMP: NEW WELL ❑ REPLACEMENT WELL MONITORING WELL# Z 4hN ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL U (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# 30 SOIL BORING 3� B 1:1 DESTRUCTION:_ 1111��, INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 1�M1c... DIA.OF CONDUCTOR CASING fJ A D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVCy LLDIA.OF WELL CASING Z—\.nc.\-, C C3PUBLIC/MUNICIPAL EIDRIVEN DEPTH OF GROUT SEAL —4 S P-r 1 -rSPECIFICATION " ac- �U R ❑ IRRIGATION/AG VOTHER GROUT SEAL INSTALLED BV %I 'C'r GROUT BRAND NAME E MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLFR:❑Yea ❑No S APPROX.DEPTH -7W I'I" LOCKING CHESTER BOX/STOVE PIPE V t--5 S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER__CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARFD 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,1 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 244 HOURS SSHIN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)4883423. COMPLETE DRAW�IINNG-AT LOWER AREA PROVIDED. L Slpned X L�0-(A-A/%-IA4— /LL V Iy�L� L'- Title 7 I'1 %r�(� �, L_J��G,1' L'I :C�l Date �J 'LJI S PLOT PLAN IDnw to Scelel 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. T _.... .....:..._.:.......i_...;.__... w IS U071 ............ ............. .............. • 7 m 3 e ar dIN D ................. ... 9 ............... ddd N N Ir1� 3 n a L o DEPARTMENT USE ONLY Application Accepted By + V\,Z+ Date `J Area 1 Grout Impaction By Date Pump inspection By Date Destruction I-pection By Date Comments ACCOUNTING ONLY: AID# I FAC# PE CODES FEE INFO I AMOUNT REMITTED E (CASH RECEIVED BY '^DATE PERMIT/SERVICE REQUEST NUMBER INVOICE �' �� ..c T �� / �� 1