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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 �D� �� (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ORIGINAL (Compll(l In Troliestl) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPWNTT�TITLE. CHAPTER 9%-1 11 5.33 AND THE�STTA/N�DA�RDS OF SAN JOAQUIN COUNTYPUBLICHEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. + JOB ADDRESSOR APN# a �.(.�21' 2_�[JL.1-f r IA, /e t; ITY -J"I �IC '7/I PARCEL SIZFJAPN# i ZEEOWNER'S NAME e/Ne DDRESS ✓ZONEqq CONTRACTOR H��I �n1 �-7 {'ate ADDRE66 _ R 1 Vl(it , �Qt. UCS ,PHONE Iz- SUR CONTRACTOR ADDRESS `�� • Y t 1 �'�� '' `' �' l tj {� `7 +' — A! ADOREt?8 ?IUC- K- Ip.�',i �' t''" LIC# ( ZG `�'� PHONE l �� 7)? TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ,MONITORING WELL #❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR f ❑ VAPOR EXTRACTION WELL # J TYPE OF PUMP) 11New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ DESTRUCTION: ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING g `� �,\ r) i> I , 3 C G -J J PE CODES INTENDED USE TYPE OF WELL N 3 CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM IVICal 12 v DIA. OF WELL EXCAVATION I I f 1 �! f DIA. OF CONDUCTOR CASINO . 3. ❑ DOMESTIC/PRIVATE flrv4Lv GRAVEL PACK/SIZE 5U✓tc( 1 Ci TYPE OF CASING/STEEL VC � �� V CCi4(, � 1' -! DIA. OF WELL CASINO D ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL6�� SPECIFICATION D ❑ IRRIGATION/AG ❑OTHER �L_ GROUT SEAL INSTALLED INSTALLEDBYY GROUT BRAND NAME 6N -t e- to R ❑ MONrTORINO r GROUT SEAL PUMPED: [�r NoYCONCRETE PEDESTAL BYDRILLER: Y[]No S� C APPROX. DEPTH _>11r% r '� �' 12, r),=,. _ �� _ LOCKING CHESTER BOX/STOVE Pt 1 ✓t'( C. hct %{ <1 �- (i� ;� t ti, i PROPOSED CONSTRUCTIONMR1WNO 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 ORDINANCi�79TATE 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 WHIC 4-'\� PHIS PERMIT 16 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBLONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrT 18 ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKM N'1 COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091 4613PROVIDED. 423. COMPLETE DRAWING AT LOWER Ai1E� 9lp810—d X/� Title � � DatN'.;% PLOT PLAN ID— to Scale) Scala ' to Z: 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED Z. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNFB AND LOCATION OF ALL EXISTING AND FROF'O SEO6. LOCATION OF WELLS WrTHIN RADIUSOF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING B'OPERTY. DEPAivMENT USE ONLY Application Accepted By Grout Inspection BY Date Pump In.pectlon By Deatructlon Irngiotlon By GG . i r date Data Data LACCOUNTING ONLY: AID/ FAC# `� �,\ r) i> I , 3 C G -J J PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISER DICE 6&A . 3.