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i� -3 APPLICATION FOR WELl1PUMPII,PEAM+ SAN JOAQUIN COUNTY PUBLIC HEALTH S CES ; ENVIRONMENTAL HEALTH DIVEISION PO. BOX 388, 304 EAST WEBER AVENUE, STMUCIN, CA%M1, 88 (2091408-3420 i MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM CATS ISSUED IComplet4 in Trtplut4) APPLICATION IS 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 STANDARDS OF SAN JOAQUIN COUNNT�YIPUBLICIHEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. t JOB ADDRESWOR APN# �AtetU ('K �[. CITY_- �?��C'jT{I PARCEL SIZE/APN# OWNER'S NAME A- L c ADDRESS / � `�YL �fi{_ L_OK�VI 41 L PHONE# CONTRACTOR �t - �c%e'LY1� ADDRESS.117� ryKS �i UCX:5MZ65('PHONE (� sly f � � SUB CONTRACTOR ADDRESS u �! F LIC/ PHONE# _ Ih 'I TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# N II� ❑ OTHER CI INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repelr N.P. DEPTH PUMP SET FT IM (TYPE OF PUMP) I11'' FIRST WATER LEVEL O ' +' 11OUTOFSERVICE WELL ❑ GEOPHYSICAL WELL# I1, SOIL BORING g i DESTRUCTION:.. i Ih 'I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION yIIIt DIA.OF CONDUCTOR CASING p ! ❑ DOMESTtCIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELIPVC iG DIA.OF WELL CASING O ❑ PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL fl 3SPECIFICATION R l ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY Il iI GROUT BRAND NAME ,E ❑ MONITGRINO GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Ym ❑Ne S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE g PROPOSED CONSTRUCTIONIDRIUJNG METHOD: MUD ROTARY AIR ROTARY AUGER `� CABLE OTHER Ii I� 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 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 I j THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.I CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 FLOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1204144119442321 COMPLETE DRAWING AT LOWER AREA PROVIDED. / 1� a Stoned X_�. ` Title i 2 La t ..✓L' �f G.�i TIl Data / /re �I II PLOT PLAN(Draw to Soulal Scale "to 1. !JAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,OLVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. GN THE PROPERTY OR ADJOINING PROPERTY. --- ....,.. ......I. �; - li 4 I � � .,.-f... .,... --- - .. .. .. ......_ _ `.. .i... ...i .. _ _ .. r-. 1 r _ ---DE ARTMENN�ONLY ryi' rvJ Application Accepted By A,.jl.Deta Grout Inspoetlon By . Data Pump irogaatlon By Date DmIrUctlen Ir»pectlon By , r Date 1 Comments' 1 ACCOUNTING ONLY: AID# FACE I .�I PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED 9Y DATE I ' PHiMtTI$ERVLCE REQUEST NUMBER INVOICE 35o z