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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />RO. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br />(209) 468-3420 <br />e P u- L NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Tripliestel <br />APPLICATION 13 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PPUUBLIC IIEALT14 SSEERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRE33/OR APN/ LQ Tc� l l� Z k CITY C (J, Y p �� PARCEL SIZF/APNI <br />OWNER'S NAME � � � (` �� ADADDRESB / t— <br />CONTRACTOR LIC � d PHONE / � C <br />,_�cL�,-0J/ � % �/ <br />BUB CONTRACTOR ADDRESS LIC( PHONE R <br />TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL / ❑ OTHER <br />❑ <br />INSTALLATION ❑ WELL 8 TEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br />❑ New EaRepelr H.P. �L <br />DEPTH PUMP SETLFT. FIRST WATER LEVEL k / O <br />R VPE OF PUMP( <br />❑ OVT-Or-SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING R <br />11 DESTRUCTION: <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />A <br />IK-OOMESTIC/PRIVATE <br />❑ GRAVEL PACK/SIZE <br />DIA. OF WELL EXCAVATION <br />DIA. OF CONDUCTOR CASINO D <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN <br />TYPE OF CASINO/STEEL/PVC <br />DIA. OF WELL CASING O <br />❑ IRRIGATION/AO <br />❑ OTHER <br />DEPTH OF GROUT SEAL <br />SPECIFICATION R <br />❑ MONITORING <br />GROUT SEAL INSTALLED BY <br />GROUT BRAND NAME E <br />GROUT SEAL PUMPED: ❑ Yes ❑ No <br />CONCRETE PEDESTAL BY DRILLER: 11Y- ❑Ne <br />APPROX. DEPTH <br />LOCKING CHESTER BOX/STOVE PIPE <br />S <br />S <br />PROPOSED CONSTRUCTIONMAILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HMBV CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERronMANCE OF THE WORK FOR WHICH <br />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 <br />THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'SCOM SATION LAWS OF <br />CALIFOLiN1AJ-1TTE11 PUCANT MUST CALL 24 i URS INA ANCE FOR ALL REQUIRED INS TONS AT (2091409-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED <br />Signed X/ Title_ P S7 <br />Date <br />PLOT PLAN (Draw to Boalal Scale ' to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPFRTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUOINO COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />PQ.1r� <br />Application Accepted <br />Grout Inspection By <br />Deatna:tlen Inseeetlei <br />Comments: <br />ACCOUNTINO ONLY: I AID► <br />DEPARTMENT USE ONLY <br />Date Pump Inapactlen BY_ <br />FAC• <br />N) <br />Dats - Aram <br />Date <br />IPE CODES FEE INFO AMOUNT REMITTED CHECK( ASH I RECEIVED BY I DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />143gu 105 O 7-)-o EK. _ 9 --�1q q 1-041?I'1 <br />Pub. Health Serv. - Enviro. 173 (3/96) <br />it <br />