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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SL :ES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 468-3420 <br />110N-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 WOW 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 APNS 5 I 5 (A) &CI <br />OWNER'S NAME .D 1)6 &PS <br />ADDRESS YS44714-1 61:* LICS-r PHONE ,(;t3 "//7 <br />ADDRESS uci q 6V-e PHONES S-0-27 ( -5— <br />CITY Sit/ L. le-len PARCEL SIZE/APNS <br />ADDRESS iirtej timeit• PHONES <br />CONTRACTOR CONTRACTOR It4r14/141 0-}Lli 2l(A c2..4 (Aii/titTh <br />SUB CONTRACTOR <br />TYPE OF WELUPUMP: NEW WELL 0 REPLACEMENT WELL <br />0 INSTALLATION <br /> <br />O WELL SYSTEM REPAIR <br />0 New 0 Repair H.P. <br />(TYPE OF PUMP) <br />OUT-OF-SERVICE WELL <br />0 DESTRUCTION: <br />MONITORING WELLS <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL # <br />0 OTHER <br />,VAPOR EXTRACTION WELL # <br />FIRST WATER LEVEL <br />)2rSOIL BORING <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />o PUBUC/MUNICIPAL <br />IRRIGATION/AG <br />54 MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />El DRIVEN <br />0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO <br />TYPE OF CASING/STEEUPVC f) iii 4.- DIA. OF WELL CASINO 2" <br />DEPTH OF GROUT SEAL SPECIFICATION <br />GROUT SEAL INSTALLED BY C I / le if— GROUT BRAND NAME PC1/11q4e( <br />GROUT SEAL PUMPED: D v.. 0 No CONCRETE PEDESTAL BY DRILLER: 0Y.. 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />CABLE OTHER <br />/4114re' eteat e I 11 <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS,LIIND RULES AAR <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 WOW FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: " I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPUCANT MUST ALL 24 HOURS IN ADVANCE FOR ALL REQUIRED I PECT1ONS AT 12001 411111-21422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />eeeeea, ( Title CV/et .-/- (7 rchj Dote ° <br />PLOT PLAN (Draw to Seale) 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 />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 />PROPOSED CONS171UCT1ONTDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER <br />Signed X <br />Application Accepted BY <br />Grout Inspection By Date <br />DEPARTMENT USE ONLY <br />Pump Inspection By <br />Dote Area <br />Dote <br />Destruction Inspection By <br /> <br />Dote <br />Comments: <br />ACCOUNTING ONLY: AIDS FAC# C c__SE,11_,L(44 <br />---`,. <br />7 \ <br />PE CODES CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />'9ipli'D <br />FEE INF;i0 / <br />kji <br />AMOUNT7TED <br />tdA. -0-1,40 11,1144v , v <br />ot'Vt4o t,,-c--nc)-