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APPLICATION FOR WELLIPUMP PERMIT <br />-_N JOAQUIN COUNTY PUBLIC HEALTH SERVIC", <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br />(209) 468.3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 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 />/OR APN.x 3 /'bJOB ADDRESS �Ui!G'/7JCITY J/C!kr=( <br />P(/A.(,R-JCjEDlL SIZE/APNx�Z3 )z — b <br />ct��.r�•v•-�� <br />PHONE �,-C4yyL-716G0OWNER'S NAMEVF ADDRESS (^l tlllCtY <br />CONTRACTOR_ ��y}�y. �"(« ;� 'r s%' ADDRESS�'�j.�K� <br />S—Ztg, UC, PHONE <br />,/ C`9 <br />SUB CONTRACTOR �/V �(I �(�(1, ®/tl ii7v l�C ADDRESS :)�C i,?'1Ji;11['/6^� � PHONE A1� <br />e�� LIcx <br />INVOICE <br />TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # <br />❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR <br />❑ VAPOR EXTRACTION WELL x J <br />❑ New ❑ Repair H.P. DEPTH PUMP SET FT. <br />FIRST WATER LEVEL O <br />(TYPE OF PUMP( <br />C1OUT-OF-SERVICE WELL G <br />GEOPHYSICAL WELL # <br />au.�,�� <br />V"o SOIL BORING <br />[ / / L❑ <br />13 DESTRUCTION: �JlfLr P:^QJf- <br />e• <br />---[�rjs�%C�'�/ C.ez21�4T <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />A <br />❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION <br />DIA. OF CONDUCTOR CASING q <br />❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC <br />DIA. OF WELL CASING D <br />LJ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL <br />SPECIFICATION R <br />IRRIGATION/AG El OTHER GROUT SEAL INSTALLED BY <br />GROUT BRAND NAME E V <br />r❑3 <br />LJ MONITORING GROUT SEAL PUMPED: ❑ Ys ❑ No <br />CONCRETE PEDESTAL BY DRILLER: ❑ Yea [IN. S <br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DFtlWNG METHOD: MUD ROTARY AIR ROTARY AUGER <br />CABLE OTHER 44A".14 rL,Z <br />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 <br />9EGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />'NIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />`HE 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 <br />JAUFORNIA <br />THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRE((D77��INSPECTION$ AT (209) 4,6[83423. <br />COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X Tltle � /�(j(7%�/ "" <br />f!r{ C. ,� Data. y <br />PLOT PLAN (Draw to Scale) Scale - to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. <br />LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS. DRIVEWAYS. AND WALKS. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />T <br />Application Accepted By <br />Grout Impaction By <br />Destruction Impaction <br />ACCOUNTING ONLY: I AID# <br />DEPARTMENT USE ONLY <br />Date Pump Impaction By <br />FAC# <br />Data _ Arae D� <br />Date <br />Date <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK#/CASH <br />RECEIV BY <br />I DA PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />� <br />— <br />3 D to/S <br />S b U wo \ % <br />V- <br />