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APPLICATION FOR WELLIPUMP PERMIT <br />'4, AN JOAQUIN COUNTY PUBLIC HEALTH SERO <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAUUIN 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 HEA <br />�L/T/)y' SERVICES, ENVIRONMENTAL HEALTH DIVISION, <br />JOB ADDRESS/OR APN# / L-� .d.t`f" (,'L -;LW CITY 7I CCy/ `�y' PARf.FI CI7F/APNR <br />OWNER'S NAME l <br />t9 A/ / 4L A/�/ ADDRESS �. �x ��l(,-I �"/sV /�,lf//147y tPHON Xy Z <br />CONTRACTOR S • � l %�,1.r�f `ni,�y�y�J�//J� ADD/RE�SSy ¢` r I ZM,yF �// UC/P/HONE <br />SUBCONTRACTOR <br />TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL X <br />❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />(TYPE OF PUMP) <br />❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # _ ❑ SOIL BORING <br />DESTRUCTION: �.L. <br />�' �� !al -D C:'tilS <br />INTENDED USE <br />TYPE OF WELL <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />❑ DOMESTIC/PRIVATE <br />❑ GRAVEL PACK/SIZE <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN <br />❑ IRRIGATION/AG <br />❑ OTHER <br />❑ MONITORING <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />DIA. OF WELL EXCAVATION <br />DIA. OF CONDUCTOR CASING <br />TYPE OF CASING/STEEUPVC <br />DIA. OF WELL CASING <br />DEPTH OF GROUT SEAL <br />SPECIFICATION <br />GROUT SEAL INSTALLED BY <br />GROUT BRAND NAME <br />GROUT SEAL PUMPED: ❑ Yea ❑ No <br />CONCRETE PEDESTAL BY DRILLER: ❑ Yes ❑ No <br />LOCKING CHESTER BOX/STOVE PIPE, <br />AIR ROTARY AUGER V1 <br />CABLE OTHER --- <br />i <br />O <br />B <br />A <br />DD ` <br />N <br />R—C <br />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 <br />�SS <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 WHIC4 <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 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 />CALIFORNIA." TH APPLICC T S CA 24 S ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1209114693423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X ly11 _Title �ar=J� Date <br />r 7r-1�' <br />i <br />PLOT PLAN (Draw to Scale) Scale to <br />1. NAMES OF'6TREETS OR ROA S 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 5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />Application Accepted <br />Grout Inspection By <br />Destruction Inspection <br />DEPARTMENT USE ONLY <br />Area � 5 0 2 <br />Date <br />ACCOUNTING ONLY: <br />AID# EAC# <br />PE CODES <br />FEE INFO <br />AAOOUNT REMITTED <br />CHECK#/CASH <br />RECEIVED BY <br />DATE PERMITISERVICE REQUEST NUMBER <br />INVOICE <br />35bZ <br />+6 <br />- <br />