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' * APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAO.UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION _ <br /> P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201.388 <br /> OJ D N (209) 488'3420-\ <br /> -� c�(Gia-Ar-1 2� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 R 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 11 S. AN, THE �JIN 4 <br /> STANDARD O SAN JOAQOUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN# � CITY , © PA L SIZN# <br /> OWNER'S NAME 1 1 ADDRESS i�O� APNEN ' <br /> CONTRACTOR 1CL DDRESS. LICK ONE <br /> SUB CONTRACTOR ADDRESS LIC# PHONE# <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL.# J <br /> ❑New❑RepaF, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ITYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING o�g- <br /> DESTRUCTION; !.(ys+F.� � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,q <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASING L <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R Q <br /> ❑ IRRMATIONtAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E Q <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes 13N. S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE g <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE HONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANC <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 WHICF <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR%HIRING OR BUB-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'*COMPENSATION LAWS OFl>,, <br /> CALIFORNIA.' TIV APPLICANT MUST CALL 24 HOUIRS IN ADVANCE FOR ALL REQUIRED I TIONS AT(2091468-3423, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Title Date L1 . <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 6. 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 /> - ... ; - i... _ <br /> -- - or <br /> - . <br /> PAYMM <br /> c <br /> . ... .. <br /> IVED <br /> ECE <br /> . ., pt/Jcc ....' <br /> !v <br /> BE 5... <br /> D994 <br /> JrAQUIN CQqNTY. ., <br /> �aF1 �QQS, PUr,I�IC.HEALTHiFRVIF <br /> 1 <br /> ...... <br /> (v1f NTAL L <br /> D N' <br /> 0- <br /> W-0.�. .... .l ; . <br /> _ 6 <br /> �DEPARTMENT USE ONLY <br /> Application Accepted By Date `2' Area <br /> Grout Inspection By DatJ P.srnp,lnspection By Date <br /> 'Y <br /> Destruction Inspeclioni9v /24 <br /> 1' <br /> Comments; tQ <br /> ACCOUNTIN43 ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED HEC ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> �n <br /> !12(D 1420 <br /> 1(/ <br /> S'9\b ul L 1 <br />