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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468.3420 ON -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I\ e rJ �� C� (Complete in Triplicate) APPLJCATIO ERE BY MADE T THE SAN JOAQUIN COU FbR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT LE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COU PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR AFNN — CITY Az _ j 4v e- K.TU 1'\. PARCEL SIZE/APNi_ INTENDED USE 4, �/'O � J I I A OWNER'S NAME Y Q11 , U. A" S � ADDRESS T DIA. OF WELL EXCAVATION �/ / PHONE I_ ,C/h CONTRACTOR' 1 P. /' /bl n ( V �l OC�I Dv-� ADDRESS N 1V / LJC✓r (0501 301 PHONE ❑ PUBLIC/MUNICIPAL 5^VN `` DEPTH OF GROUT SEAL /O f CE' �D V❑ SUB CONTRACTOR6�4� /YlL I DT 1 nr, ADDRESS GROUT SEAL INSTALLED BY b grt tk ,"' V� LJC,f 5r2 1aB PHOT Ma i5? IZ TYPE OF WELL/PUMP: Id NEW WELL ❑ REPLACEMENT WELL M MONITORING WELL . A ! 0 OTHER ® INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL t J ❑ New ❑ Reo it H.P. _ DEPTH PUMP SET" FT. FIRST WATER LEVEL O ff'!PE OF PUMP) _ ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL X ❑ SOIL BORING B ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �` I A ❑ INDUSTRIAL ❑ OPEN BOTTOM T DIA. OF WELL EXCAVATION �/ DIA. OF CONDUCTOR CASING A D O ❑ DOMESTIC/PRIVATE ' ❑ GRAVEL PACK/SIZE Jq J Y1l.T TYPE OF CASING/STEEL/PVC V DIA. OF WELL CASING II D ❑ PUBLIC/MUNICIPAL ❑ DRIVEN -- `` DEPTH OF GROUT SEAL /O f CE' q SPECIFICATION O - GD �JfR V❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY b grt tk ,"' GROUT BRAND NAME E pI MONITORING(1�� GROUT SEAL PUMPED: ❑ Ys ONO CONCRETE PEDESTAL BY DRILLER: ❑ Yee ❑ No S APPROX. DEPTH ...L/ .I 4 LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTION/DHIWNO METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER I HEREBY 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 WHIC 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 FOLLO LNG: I CERTIFY THAT IN T E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORN HE CANT MUST C 24 HO IN ADVANCE FOR ALL REQUIRED IN ECTIO3 pNS AT 120Y1 458423, CO PLETE DRAWING AT LOWER AREA PROVIDED. Slaned X Title Gr1Y�`D r� G & L Dete �i PLOT PLAN (D— to Scale) Scale ' to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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.