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APPLICATION FOR WELLIPUMP PERMIT ) t AN JOAQUIN COUNTY PUBLIC HEALTH SERV1 ENVIRONMENTAL HEALTH DIVISION r P.O. BOX 388.304 EAST WEBER AVENUE, STOCKTON, CA 5520 388 (206) 468.3420 1, .4 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICemplets in Tripliests) APPLICATION 16 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE ANDARDg`OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ST- CITY &o of tr ' I Al, `�� PARCEL 81ZElAPNIr JOB gpDRES8/0R APN# f C�� !` r^ - ]I �GL Y fin ros 1Gr'N►/!4 J4 ADDRESS f [ " �Z PHONE# OWNER'S NAME 3/�- /_ r ��[�, ( �/L 5 ADDRESS LIC# PHONE# ZLL 1 f� CONTRACTOR SUB CONTRACTOR��44-�, ADOREBB I/t�L LU UC+r � PHONE>y 1 f TYPE OF WE MP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑Naw❑Repair H.P. DEPTH PUMP SE-r----YT. FIRST WATER LEVEL D t (TYPE OF PUMPI {�/ J� ❑ O:U.T-OO -SERVICE WELL ❑ GEOPHYSICAL WELL# BOIL BORING S ( DESTRUCTION: f Pt�S(.��P_ YD[�F r. 1 INTENDED USE +� TYPE OF WELL CONSTRUCTION SPECIFICATIONS '4 LI ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.Of CONDUCTOR CASINO J O ❑ DOMESTICIMVATE ❑GRAVEL PACKISIZE TYPE Of CASINGISTEELIPVCEV( DIA,OF WELL CASING^ 4 0 ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY .C"[. Pf LMh (TROUT BRAND NAME E ! ❑ MONITORING GROUT SEAL PUMPED:It Vas ❑No CONCRETE PEDESTAL BY DRILLER: Yee ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIMLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REG 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 IB PERMIT I ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES HE FOLLOW( G: 'I CERTIFY THAT IN TH RMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIOAAN'S COMPENSATION LAWS OF UFORHIq." THE MUTT URS IN ADVANCE FOR ALL REOIARED INSP�EC]TN/]+N�S AT 120YI4pJ42]. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slurred Title ///j�.[ib - _. ..___..-. Date ~�� ^� Gr ^ PLOT PLAN(Drew to Scale)Seale "to 1. NAMES OF STREETS OR A NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED- 2. OUTLINE OF THE PROPS GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OtrTUNES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. ....... ...._-. _........... ....... -.. i .... ...... ...-.:. : ., ...:.... ..-. ...,:.,...- i - - ......:. . ............ .i... DEPARTMENT USE ONLY Applleetlan Accepted By � Date �`3�6 Arse � Grout Inspection By Date Pump Inspection By bate ' Destruction Inspection By i Date Comments: ACCOUNTING ONLY: AID# FAC# J `-' i PE CODES FEE INFO AMOUNT REMITTED CHECK#ICA$H RECEIVED BY DATE PHLMITlSERVICE WMT NUMBER INVOICE 1�-' Lj - l 1