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APPLICATION FOR WELUPUMP PERM N\�V SAN UOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION CKTON CA 95202 �,304 EAST WEBER AVENUE, STO o\\ oa,� (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED DJC 601 11, (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS A ICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115 3 AND THE STANDARDS OF SAN JOAQUIN C UNTY PUBLIC HEALTH SERVICES,ENVIR L HEALTH DIVISION. I �f' I�Or b� ,� PAR L SIZE/APNF y JOB ADDRESS/OR A NR0117-A 1` 7 CITY_� .a�' PN OWNER'S NAME '� O ADDRESSIYI ml PHONE/ L CONTRACTOR �fY_1TR U 1 - ADDRESS �M LTC# PHONE Rjv�:e R-Z— SUB CONTRACTOR _ADDRESS LIC# PHONE# TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL IF OTHE ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New❑Repeir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) 11 OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING/ (/'W B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS '4 ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.or CONDUCTOR CASING_ O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CASING D nn p�,�n El PUBLIC/MUNICIPAL 11L I \DRIVEN DEPTH OF GROUT SEA ) My �d ir�1Z SPECIFICATION R ❑J[iRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROAT BRAND NAME E /y�_U`/MONITORING /T 1 GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:13Y. ❑No S APPROX.DEPTH (/� LOCKING CHEST BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRTLUNG METHOD: MUD ROTARY AIR ROTARYAUGER CABLE OTHER 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,AND RULES ANO REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH 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 THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE V40FW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFO THE APPIJCPAT MU CALL 24//OARS IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT 120914041-3423. COMPLETE DRAWING AT LOWER AREA /DED, 9lpned X Title � tC!rG-r!� Date G PLOT PLAN ID,aw to Soale)Scale -to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 7. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS"THIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. Y .. i J DEPARTMENT USE ONLY aw ow Date Area :oolicetlen Aeceroted By G,a t in.pectlen BY Date Pump Inapeetion By Date Date Dmaowtion Iropectlon By CemmMNa t- Z co Tec "t 1)4)17- (hf/ g2j wg. /4- S t7T- ACCOUNFINO ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(1/97)