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APPLICATION FOR WELLIPUMP PERMIT PAYMENT 005-3 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION ,1�- Pi fA ' P.O. BOX 3 304 EAST WEBER AVENUE, STOCKTON, CA q�1� 4b 88, (209) 468.3420 -A�� PUBLIC ii AI.,TH jLPvlr1C NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HLA011 CimjION (Complete in Triplicate) 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 JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPT€R 9-1 11 5.3 ANDZ11/w E STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OftAPN/N..,,�� 7 ACJ ' A- C /�e�� e_'- CITY </ PARCEL SIZE/APN! '� //ii;'19�6:'1� T , A / '�L • ADDRESS5.h /V' 00 / / PHONE OWNER'S NAME rY% LAi � J L.G � L .Gv:. ADDRESS 7 )J t0't �! , �%' C! —PHONE #/, .n SUB CONTRACTOi(7i' I IST C��'1�1%I .�I % JL t�' �L 2 2� -- _�7 C]. J'/ ADORES6 �•:.I• [7LJX,rT. '`iJ(�1.1'itCl't 'LICA' 'tl� PHONE I ^/`>•''�"l'T7 TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL. ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELLI 11New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) DESTRUCTION ❑ OUT -OF -SERVICE WELL In9w ❑ INDUSTRIAL ❑ OPEN BOTTOM ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE ❑ PUBLIC/MUNICIPAL ❑ DRIVEN ❑ IRRIGATION/AG ❑ OTHER MONITORING APPROX. DEPTqj)y' �(? C,• ' �7�� PROPOSED CONSTRUCTION/DRILLING METHOD: MUD fl ARY ❑ GEOPHYSICAL WELL. aifP':4^t -i CONSTRUCTION SPECIFICATIONS DIA. OF WELL EXCAVATION TYPE OF CASING/STEEL/PVC r V6 DEPTH OF GROUT SEAL '" 7U ` GROUT SEAL INSTALLED BY GROUT SEAL PUMPED: ❑ Yea [IN. ❑ SOIL BORING . l DIA ('OF OF CONDUCTOR DIA. OF WELL CASING �g B A SING p` n SPECIFICATION R;�- GROUT BRAND NAME Ek CONCRETE PEDESTAL BY DRILLER: ❑ Yes ❑ No S l' LOCKING CHESTER BOX/STOVE PIPE S AIR ROTARY AUGER_ CABLE OTHER I HtHter cert ntY THAI 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 WHICH 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 FOLLOWING: " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORWIAHE CA, MUSTC 24HOURS IN DVAIVCE FOR ALL 1RE11"AED I PECTIONS AT 12091 460442?. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X- Tltle Cy��' /('�44-37 Date�vtJ�,,� PLOT PUN IDrwv Saalsl 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 PROPFRTY Applicetlon Accepted By � —lhk `J Grout Impectlon By Destruction Inspectlon By Date DEPARTMENT USE ONLY Date r1b Area� �� Pump Inspection By Date Date ACCOUNTING ONLY; AID# FAC. PE CODES FEE INFO AMOUNT REMITTED CHEC�K;ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE