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Signed X <br />Area Date <br />Date <br />APPLICATION FOR WELLIPUMP PERMIT <br />AN JOAQUIN COUNTY PUBLIC HEALTH SERVI, <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />(209) 468-3420 <br />NONREFUNDABLE 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN# LI ci J .A./(13t fri_e• CITY 7''m C PARCEL SIZE/APN# <br />OWNER'S NAME 5 i-- c.„ I ADDRESS cpi. <br />Qt. r,i vi <br />REPLACEMENT WELL MONITORING WELL # <br />CONSTRUCTION SPECIFICATIONS <br />10 DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY 10/ <br />GROUT SEAL PUMPED: El Yee 0N0 <br />LOCKING CHESTEfiELDX/STOVE PIPE <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING <br />SPECIFICATION <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: CI Yee 0 No <br />AIR ROTARY AUGER CABLE OTHER <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />d MONITORING <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />0 DESTRUCTION: <br />(TYPE OF PUMP) <br />NEW WELL <br />INSTALLATION <br />New 0 Repair <br />OTHER <br />VAPOR EXTRACTION WELL # <br />FIRST WATER LEVEL <br />SOIL BORING <br />TYPE OF WELUPUMP: <br />WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />H.P. DEPTH PUMP SET <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # <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 ALL REQUIRED IPPECTIONS AT 1209)408-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />P <br />PLOT <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />Data . 21 \61 5 <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />Title \'3 L A' 1\-1 1. <br />N (Draw to Scaled Scale • to <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Pump Inspection By <br />Comments: <br />ACCOUNTING ONLY: AID# FAC# ar1-51G - 4i <br />PE CODES FEE INFO AMOUNT REMITTED CHECKCCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />Date <br />DEPARTMENT USE ONLY <br />IL <br />PHONE # <br />CONTRACTOR C ary j:;-; ADDRESS 41410f-*Cd4---- PHONE # `.274.)33 73730 <br />v SUB CONTRACTOR fri eih- ADORESSI) ) 6' (.2te PHONE #‘/11.185-..e.155-Y <br />reY <br />0 <br />A <br />1?