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(sh,J.c <br />ro <br />APPLICATION FOR WELLIPUMP PERMIT <br />IN JOAQUIN COUNTY PUBLIC HEALTH SERVIL <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <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 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN# On/ 4(,6"51- fi1it/17 /7't>/ /241 CITY rtC PARCEL SIZE/APN# <br />OWNER'S NAME ADDRESS 4:NW fit /...)41 iv et ere/ i)c-1. PHONE # <br />CONTRACTOR IS CA.E' L:it) -1--fr C. ADDRESS 2 - • IA_ (Pt PHONE # 570' 43 IT7W <br />SUB CONTRACTOR I-4 a-c,ke_L I IiI \ (1,--•E-14 fYlLI, J74-t...., ADDRESS PO R.) A z_z3 ?.4...411.li uc#6,7,;(‘) '7 PHONE #57/64.5.9 d V531( <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />NEW WELL <br />INSTALLATION <br />0 New 0 Repair <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />0 MONITORING WELL # <br />0 CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />OTHER <br />VAPOR EXTRACTItIN WELL # <br />FIRST WATER LEVEL 0 <br />SOIL BORING OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # <br />0 DESTRUCTION: <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE a . 3 C.- TYPE OF CASING/STEEUPVC <br />.20- ..7 Ric, <br />INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION < ' ' DIA. OF CONDUCTOR CASING 0 <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />DIA. OF WELL CASING D <br />PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL 2 I ' SPECIFICATION R <br />IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY ,-4,r4 11-.t GROUT BRAND NAME E <br />5 MONITORING GROUT SEAL PUMPED: El Yes CI No CONCRETE PEDESTAL BY DRILLER:11 Yee 0 No s <br />APPROX. DEPTH LOCKING CHES.,...L......TEI.:...51 1 1C/STOVE PIPE S <br />PROPOSED CONSTRUCTION/DRILLJNO METHOD: MUD ROTARY <br /> <br />AIR ROTARY AUGER CABLE OTHER <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 />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 <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." THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR AU. REQUIRED SPECTIONS AT 1209) 465-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed ebt."-fiL\ Title ‘i 1\i4 Date Z <br />PLOT PLAN (Draw to Scale( Scale to <br />1. NAMES OF STREETS OR ROADS 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 />NJA-v-k <br />II <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Area <br />Grout Inspection By <br /> Date Pump Inspection By Date <br />Destruction Inspection By <br /> Date <br />Comments: <br />ACCOUNTING ONLY: AID# FAC# kC () 5-(,_. 9 ( / <br />PE CODES FEE INFO AMOUNT REMITTED CHECKCCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE