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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 (209) 488.3420 �' I) MON-REFUNDABLE PERMR EXPIRES 1 YEAR FROM DATE ISSUED (carnpllb In rriprKaa) IJ -PLICATION 18 HERE MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANR/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE V H SAN OAQUIN COUNTY DEVELOPMENT TITLE, (�C1HAFTER 8-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION, :OB ADDREBSPOR APNI .� .._ ,y S 1 `- 1 u O T- }-fit-� �� t CITY �(�� O��i(Q� 711c PARCEL SIZVAPN, ` 5 �ISo�3o IWNER'9 NAME i 1�,� ADDRESS 1 YJOx I�CrQS,� J 1(-}tp'1 PHONE, :ONTRACTOR_ 61q=" _ �n V 1(c 'P )�j `A , ADDRESS—) 5 Ll LA r?1��'Y��^1/\wTl�p� LIC, 1 'D tp O PHONE / J :US CONTRACTOR , I L l wl , V� _� - ADDRESS_ J ,te vI a (0� ( SS PHONE, YPE OF WELLPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ;91RONFTORING WELL I -?` ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBB{ONECT REPAIR ❑ VAPOR EXTRACTION WELL , ❑ "YPE OF PUMP) N. ❑ f4p•Ir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ❑ OUTOFSERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BOfVNO J DESTRUCTION: irFHOFn IJsR INDUSTRIAL ❑ OPEN BOTTOM DOMESM/PWVATE ❑ GRAVEL PACKIBQE J PVBUC/MUNICIPAL DRIVEN IRRiGAMNFAG ❑ OTHER MONITORING D•t• Ptmo Irro•ctl— By 'PROX. DEPTH 1 tOPOSED CONSTRUCTIONFDROWNG METHOD: MUD ROTARY DIA- OF WELL EXCAVATION V `` /1 I 1 TYPE OF CAStNOrSTEELIPV'C V L DEPTH OF GROUT SEAL c / GROUT SEAL INSTALLED GROUT SEAL PUMPEDI-pm Yr [IN. LOCKINO CHESTER BOXISTOVE AIR ROTARY AUGER_ DIA. OF CONDUCTOR D DIA. OF WELL CASING 2�L SPECIFICATION -\ GROUT BRAND NAME OY�\0. jr`Q.. CONCRETE PEDESTAL BY DRILLER: ❑ Ys. ❑ No 5 - CABLE OTHER !E'tEBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANQF,' GULATIONS OF THE CAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOFK' FOR WHI 41S PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKINAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFI IE 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 VJFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURRED INSPVCT10N4 AT (2") 4&8.3423. COMPLETE DRAWING AT LOWER AREA VIDED. ,—d X TIN. / .:�� -, �'� may' D•t• PLOT PLAN (Or— to Be•I•I Saw • to NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PAOPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 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, MVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, .......................... ............................... ::::.:;... . ............................i . ( :... .. .......:.:::: ... . . ......._............ .. .............. .. ice.... .. }.. y.. p.. .. .. ....y.....:.....:........... . .. .. .. .... i:...,....... .. .. ..• ..•.. ..... .• .. ... {....r•. ,•.... i......'::.......••........... i..... • ...0 .............•......:.•.• ..,� • . I! .. ..... ..... Aoo•eted DEPARTMENT USE ONLY >Ih•tlen Byi��- - D•u Ar" �.t In•oectlort By D•t• Ptmo Irro•ctl— By D.t. rtr4CtiOr1 In•tr•ctbn By --t.: • D•I• ACCOUNTING ONLY: AID, FACE 'I CODES FEE INFO AMOUNT KEFArrTED CH I AIH I RLC EIVED 2y DAT " MT/SUMCE RECUFIT NUMIa1 INVOICE 66 V I C' L -Z ;i 13i�,