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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SER ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (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 19-111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# ��Q,tUIL/` �TaCI� �)�i.'+ � <�r CITY [I-1(„ C,-/� PARCEL SIZE/APNX OWNER'S NAME �LI,L1_n�:'�"t .� T(`Vl C-1 ADDRESS3-' -)(, Tr--14.A,kCj �i-LC/:-V(V tir4 Z)4 PHONE X IiS)�jL�-..J�tJL CONTRACTOR AR/N1 ADDRESS kic Ij�`(,(,l!11,, S,�IC., L�+%.�)rj 6CN PHONE X"! 54 Gy SUBCONTRACTOR CJI...-F} ADDRESS'�O'(1 TWIN PAL,,j, jjji, J CA0CLICX Lr�`J�7G PHONE# kE) S 1j' TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ 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 i1 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I;, DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC r}i 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 G GROUT SEAL PUMPED: ❑Yes [IN. CONCRETE PEDESTAL BY DRILLER:ElYesNo S � APPROX.DEPTH t(� Cfs LOCKING CHESTER BOX/STOVE PIPE PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER f�ik-V I 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 APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR JAREQUIIRED INSPECTIONS AT 1209)4683423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X / / A � I -�'Ai�'hTitle ='��= - Date PLOT 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. 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. .. _. . cu- c_ ne- 77 P . / DEPARTMENT USE ONLY r1 Application Accepted By 71N,"'v Date I /�. Area r, Grout Inspection By Date Pump Inspection By Date Destruction Inspection By Date Comments. L'IL � ',/vNsl��/��/�VJ hfi� l✓� lit .71 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE i