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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 />MONITORING WELL I <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br />It DESTRUCTION: Pg.4.-1--60 (..9.Fet-/T <br />CABLE OTHER <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER <br />.25 /I <br />DIA. OF WELL EXCAVATION <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />,ErMONITORING <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING 2. <br />(„1.-- DEPTH OF GROUT SEAL 5 SPECIFICATION <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME Rat-n-KIJD e-c21/4A0.01- <br />GROUT SEAL PUMPED: 0 Yee 0 No CONCRETE PEDESTAL BY DRILLER: El Yee 0 No <br />TYPE OF CASING/STEEUPVC pvc_ <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 K73 <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 AP il CA T MUST CA 4 HOURS IN ADVANCE FOR AU. REQUIRED INSPECTIONS AT 12091468-3423. COMPUTE DRAWING AT LOWER AREA PROVIDED. Zo <br />) Title 'PIO -kozirPix oF Opozi---71-1-,J 5 Date 4 -2-0 -i 5 P <br />PLOT PLAN (Draw to Scaled Scala to <br />. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />FAG!! AID# ACCOUNTING ONLY: <br />Date gill Sig S L • Ps Area <br />Date <br />bitzt <br />(14 <br />Date <br />Grout Inspection By <br />Destruction Inspection By <br />Comments: <br />DEPARTMENT USE ONLY <br />Application Accepted By Oti7,11-eJ <br />Date Pump Inspection By <br />PE CODES FEE INFO AMOUNT REMITTED CHECKN/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />670„ 00 ri kl.-- 1//) 17( t'„ <br />( <br />00 <br />cS.(77' <br />Slurred X <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />El New 0 Repair <br />(TYPE OF PUMP) <br />JOB ADDRESS/OR APN# rido PotkD <br />OWNER'S NAME ELTS /1/44 PAN. <br />CONTRACTOR MValitebt 6r..1.)Cr)virtyriteAlki <br />SUB CONTRACTOR-Th(4115g- 0-N.-6421:Tem <br />ADDRESS - BOX otni eik PHONE #cf41 <br /> <br />ADDRESS) tips 04Aftpo ucx Vi?0 z 2.1 PHONE $CL-% -02 64 <br />..trrce--7-on.) 95 zA -7 <br />ADDRESS , F rae.elEPett..0 , So L1C# 4027 2.-D PHONE jtic,...„ co-a-Dno4 CA <br />CITY —1-i24e.Jki PARCEL SIZE/APN# <br />OTHER <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />SOIL BORING <br />4. 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.