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APPLICATION FOR WELLIPUMP PERMIT ,AN JOAQUIN COUNTY PUBLIC HEALTH SERVI 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APINX I1 V 3 —SC' l; / N id ,J •JJ.,�/ACE -f CITY .5" / C J—!L`�J' PARCEL SIZE/APN#r ❑ INDUSTRIAL OWNER'S NAME CA ,\ Iax.nt: � /[, '� ro Ae).r T 0 f7,dv ADDRESS � /j �(� / J N C`' L, -,/tet g 4')'qY PHONE ❑ GRAVEL PACK/SIZE J CONTRACTOR 6, L C,GY 7 CIJLIL kd A4L_,1rA c. ADDRESS lkd LIC# PHONE N 11! J) SUB CONTRACTOR j 4j % J•1 F+M Z,4, I, _r IJ JL c.i.JC, CL K', 1� ADDRESS JL•31 r t:; 5 }'� L L--� a J4'- LIC# _4� PHONE AW1 "VL GROUT SEAL PUMPED: KYes ❑ No CONCRETE PEDESTAL BY DRILLER: XYes ❑ No S Pi- Lof-[ tL�� LOCKING CHESTER BOX/STOVE PIPE TYPE OF WELL/PUMP: X NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR VAPOR EXTRACTION WELL X� J ❑ New 11 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 A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION / C1 pp DIA. OF CONDUCTOR CASING ,i�1 S� O ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE J t, �'�- ❑ PUBLIC/MUNICIPAL ❑ DRIVEN ofyC°'TCI li_�'/ ��4 TYPE OF CASING/STEEL/PVC DEPTH OF GROUT SEAL DIA. OF WELL CASING D SPECIFICATION R ElIRRIGATION/AG OTHER / )/ GROUT SEAL INSTALLED BY /VAS% liAZ.Lfa'T GROUT BRAND NAME E % MONITORING GROUT SEAL PUMPED: KYes ❑ No CONCRETE PEDESTAL BY DRILLER: XYes ❑ No S APPROX. DEPTH I(i l'J J)'�E'T" LOCKING CHESTER BOX/STOVE PIPE B PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9EBY 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 APPL%ANT MUST CALL 24 HOURS N ADVANCE FOR ALL REQUIRED INSPECTIONS AT (209) 4663423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed — Title '-'L -.i C i �. - t ! C' :� t r -CIL % Date 'If" PLOT PLAN (Draw to Seale) Scale " to 1. NAMES�DF TREETS OR ROAbS NEAREST T OR OUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINTHE PROPERTY, GIVING DIME SIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 5. 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. hes,, o.....F✓QXL��._..i +tgT,4..... Application Accepted By Grout Inspection Destruction Inspection DEPARTMENT USE ONLY 7 C, / Date T Y 15 Pump Inspection Date { / ( J Arse �J `"1 Date Date �i ACCOUNTING ONLY: AID* FAC# -11 PE CODES FEE INFO i AMOUNT REMITTED CHECK*/CASH RECEIVED BY DATE PERM UEST NUMBER INVOICE << < 1Z 2-