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APPLICATION FOR WELLIPUMP PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (C4mpbt9 In Ttiprwats) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW 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. SG JOB ADDRESSOR APNI AN'Vl�c dr 1 y tC.0-,LL.\1 l�c'L�t-�G`-'� 1 CITY ' • 7S � C< � PARyCEL SIZE/APN/ OWNER'S NAME ZiCr' .A).� OOSEII�J . PHONE f LI(yS-'�l-�•� CONTRACTOR' - - ADDRESS ,Acs C I PHONE s SUB CONTRACTOR �-�1 E2 ��.�.V\1\ IC'�c11 CI„�yY�' ADDRESS L1C1 PHONE 7 �� "ciS 1-7 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) Cl OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ,SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A \I ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ,� DIA.OF CONDUCTOR CASING �IJ k D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC IL%1 DIA.OF WELL CASING 11.x- D Cl PU13UCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION / R ClG IRRIGATIONIAG OTHER .fin\OV`V`f{' GROUT SEAL INSTALLED BY DX-��LC GROUT BRAND NAME L CQ /Q YI,L-r E T MONITORING ^O ^ ` lJ GROUT SEAL PUMPED: *. [INoCONCRETE PEDESTAL BY DRILLER:❑Yse CIN. S �L+I APPROX.DEPTH LOCKING CHESTER 80%!STOVE PIPE S :I PROPOSED CONSTRUCTIONMAILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 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 AN( 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 WHIC• THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIE THE FOLLOWING: 'I CERTIFY THAT IN THE rRFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O CALIFORNIA." Tn AITLICANT 9T CAL;Lj HOURS IN ADVANCE FOR ALL REQUIRED[INSPECTIONS AT(2-0{9)4"3423. COMPLETE DRAWING AT LOWER AREA PROVIDEEDD.I(, Slpned X Title Date PLOT PIAN(Draw to Sulal Sulo 'to 1. NAMES OF ST ETS OR ROADS NEAREST TO OR BOUNCING 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 S. 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. .. :. [,_ r .}'LO/�' DEPARTMENT USE ONLY / Application Accepted By /v l`' \ �1(X, Date V /r Area Grout Irnpatlen By Date /u Ptmtp l—pectlon By Date Destruction Irnpectlon By Date /-," r • ACCOUNTING ONLY: AID# FACS PE CODES FEE INFO AMOUNT REMITTED CHE CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE