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APPLICATION FOR WELLIPUMP PERMIT
<br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERV.
<br />ENVIRONMENTAL HEALTH DIVISION
<br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388
<br />(209) 468.3420
<br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED
<br />(Complete in Triplicate)
<br />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
<br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION.
<br />JOB ADDRESS/OR APN# ✓'V V J ��� �; r� '') ,S ��(,[,�t
<br />CITY S tL'L-k N 1"f .
<br />PARCEL SIZE/APN# 3 Ac -
<br />OWNER'S NAME
<br />«L/h'>�-�'a
<br />/J �Sfir,�t /t)
<br />ADDRESS STf_CK ,Z/' l„Q Z152r� PHONE#2(`e' �ii-r• � �3
<br />CONTRACTOR
<br />Cit=VC-C,:, ta1.,,
<br />,`y; 1 A t4 /TI7,1
<br />fJ ADDRESS hCnt,/x> hr*-CQ,a_:", L�.'I •3i7..,.LUC# -- PHONE #II7/L-• 1 ')i/S
<br />SUBCONTRACTOR
<br />•�r/v �.1%/Lt-1
<br />vim
<br />ADDRESS I,`' 13CASIL Urai,4 LJC#' 71,q 1,Y PHONE+Mkt,
<br />C A /7'/' 3 I s
<br />DEPTH OF GROUT SEAL SS/G�li.v,i
<br />�)�F"
<br />II;' �tjA'// L, SPECIFICATION '5 J��4xy- TG'`,Pd� R
<br />TYPE OF WELL/PUMP: ❑ NEW WELL
<br />❑ REPLACEMENT WELL
<br />MONITORING WELL # AfAl -i1 ❑ OTHER
<br />MONITORING (MW •i/),)
<br />❑ INSTALLATION
<br />❑ WELL SYSTEM REPAIR
<br />❑ CROSS -CONNECT REPAIR t' �` f J� /r-:-��� LA VAPOR EXTRACTION WELL # J I�/�f 'Z J
<br />APPROX. DEPTH �/) I• tib,
<br />❑ New ❑ Repair
<br />H.P.
<br />DEPTH PUMP SET FT. FIRST WATER LEVEL L• y F f. O
<br />(TYPE OF PUMP)
<br />AIR ROTARY AUGER}
<br />❑ OUT -OF -SERVICE WELL
<br />❑ GEOPHYSICAL WELL # ❑ SOIL BORING B
<br />❑ DESTRUCTION:
<br />1
<br />/L��da i\C.A
<br />- l
<br />��_t_� �xIS lI Ki4 l-.��/�
<br />,tom /J l
<br />Al -,i-1y 111 �J,C,,/ r�AiL �'/i: 1. / L L 1, 1-%/?// �gl/w'VAI 'Zf
<br />I
<br />INTENDED USE
<br />TYPE OF WELL
<br />CONSTRUCTION SPECIFICATIONS
<br />A
<br />❑ INDUSTRIAL
<br />❑ OPEN BOTTOM
<br />ll
<br />DIA. OF WELL EXCAVATION &)
<br />:Z0 .!e DIA. OF CONDUCTOR CASINGJ D
<br />❑ DOMESTIC/PRIVATE
<br />❑ GRAVEL PACK/SIZE
<br />TYPE OF CASING/STEELIPVC J'��
<br />DIA. OF WELL CASING [�/v,/J LI V��1, Z� D
<br />❑ PUBLIC/MUNICIPAL
<br />DRIVEN
<br />DEPTH OF GROUT SEAL SS/G�li.v,i
<br />�)�F"
<br />II;' �tjA'// L, SPECIFICATION '5 J��4xy- TG'`,Pd� R
<br />❑ IRRIGATION/AG
<br />�+❑pp `' ,,,J
<br />IN OTHER Vn/d:. G- /1//C.:'►: J �,,," GROUT SEAL INSTALLED BY
<br />J
<br />GROUT BRAND NAME l�Crl I C( 6,,1,a�f E
<br />MONITORING (MW •i/),)
<br />GROUT SEAL PUMPED: KY. [IN.
<br />CONCRETE PEDESTAL BY DRILLER: [1Y.. ❑No S
<br />APPROX. DEPTH �/) I• tib,
<br />^n (
<br />/4
<br />V44-2)
<br />Lf1M •� Y - Z) J L M.
<br />(h4t,,% 1I, LOCKING CHESTER BOX/STOVEPIPE%
<br />C ., CLL' {,% S
<br />r
<br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY
<br />AIR ROTARY AUGER}
<br />X CABLE OTHER
<br />1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE 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 PERFORMANCE OF THE WORK FOR WHICH
<br />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
<br />THE FOLLOWINGS 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
<br />CALIFORNIA.ZT APpLJCANT ST CALL 24 HOURS 1 DVANCE FOR ALL REQUIRED IN�r/IONS
<br />/A/T,JjOe) 4e83423. COMPLETE DRAWING AT LOWER AREA P��R[O/)VI EgD.
<br />Signed X G '' y s � Tltle ` L- ' �V llm(- Date � ( \_
<br />PLOT PLAN (Draw to Scale) 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 PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS.
<br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. V
<br />CTRIIrTIIRFC mr I I Inmr r'n VFRFn ARFGC CI Ir'N GC PATMIZ nA1X/rWAVC ANTI WAI KA (IN TNL Mn PF nR en 1—NIun I--
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<br />Application Accepted By
<br />0 --
<br />DEPARTMENT USE ONLY
<br />-`•�� /Q� /j_/
<br />Date / � ' 1 K�� Area
<br />`^ n �� /�
<br />Grout Inspection By y' V y y � \ Date ump Inspection By Date
<br />Destruction Inspection By Date
<br />ACCOUNTING ONLY: I AID# FAC#
<br />PE CODES
<br />FEE INFO
<br />i AMOUNT REMITTED CHECK#/CASH
<br />RECEIVED BY
<br />DATE P ER INVOICE
<br />
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