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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 <br />made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br />Services, Environmental Health Division. <br />Job Address/or APN# S`C C CyZCl,)k,4)✓ ANZ City S�L`kT% Parcel Size/APN# <br />r lrT- Ce (CN t T� r Kk +,ZkS Tt,A0 Phone # ,Ifc _ 743 <br />Owner's Name �t K 1 Address IVB C��T� <<� �1•. �-' ( ` <br />Contractor 1?1CFV(ZAddress 130 ` Lic# Phone #712- t'ic <br />f�Sub Contractor SVLZ712.N>L—IJV- lYL(CLt Address2ti5�0 ' t ��1C 5'W Kibw LicACO'YQZ(:? Phone # ►�-�� <br />((� TYPE OF WELL/PUMP: [) NEW WELL [) REPLACEMENT WELL [) MONITORING WELL # [) OTHER <br />DESTRUCTION ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # A SOIL BORING <br />[) INSTALLATION [) WELL SYSTEM REPAIR [I CROSS -CONNECT REPAIR [) VAPOR EXTRACTION WELL # <br />v (TYPE OF PUMP) <br />INTENDED USE <br />INDUSTRIAL <br />11 DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />[) New [) Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />TYPE OF WELL <br />[) OPEN BOTTOM <br />GRAVEL PACK/SIZE <br />DRIVEN <br />[) OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION_ <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />DIA. OF CONDUCTOR CASING W. <br />DIA. OF WELL CASING _ Cl? <br />SPECIFICATION <br />GROUT BRAND NAME <br />[) MONITORING GROUT SEAL PUMPED: [) Yes [) No CONCRETE PEDESTAL BY DRILLER: [I Yes ❑ No <br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br />}� J <br />LI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br />O State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I <br />n ^ certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br />1Vl✓�J\laws of California." Contractor's hiring or sub -contracting signature certifies the following: " I certify that in the performance <br />of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br />MUST CALL 24 HOURS+ IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (209) 488.3423. Complete drawing at lower area provided. <br />Signed X L• iL Title RLZ`- � �Z ,L f S I Datel -7 -cot <br />PLOT PLAN (Draw to Scale) Scale i to <br />Z` Il <br />1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or - <br />2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br />3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br />structures, including covered areas such as patios, driveways, the property or adjoining property. <br />and walks. <br />V 44� <br />DEPARTMENT USE ONLY <br />Application Accepted By� <br />L 4LI Date �� Area <br />Grout Inspection By <br />Destruction Inspection By <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED <br />.. l yAM <br />Date Pump Inspection By _I Date <br />Date / 1 Comments: <br />FAC# <br />H REGJEIV,ED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />C0 <br />