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FK S APPLICATION FOR WELLIPUMP PERM4j'-Y .� SAH JOAQUIN COUNTY PUBLIC HEALTH SERM41 �r ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON,CA 85201.388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ] lC6mplati iD Tripiiwtal j APPLICATION I6 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 JOAQUIN COUNTY DEVELOPMENT TITLE,,JCHAPTER 9--J1111.5.,3�A�N"o]THE STANDARDS OF SAN JOAQUIN COUNTYPUBLICHEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. I JOB ADDRESSOR APNR�1y +" "' ' ✓ �—^ra'` C�� .yam"�r� Im7 ��'' PARCEL SIIZEIEIAPNI OWNER'S NAMf " ADDRESS!/l 7 N�3 •m�lF�i�Y` /X/' t40NE♦ JI _ � J�z�y ' CONTRACTOR Y ►^ ADDRESS/�O3�''��''� AlLAJ> .�r O ZZ PHONE sO SUB CONTRACTOR ill G�.>^-Ca 'l ADDRESS�t ,y PHONE ljj &Z� TYPE OF WELLIPUMP:. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrrORtNG WELLi OTHER C/L+�' ^• 'If'.❑ INSTALLATION '❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ❑New❑Repair H.P. �� DEPTH PUMP SET Fr. FIRST WATER LEVEL p v [TYPE OF PUMP) ❑ OIJT•OFSERVICE WELL [3 GEOPHYSICAL WELLK ❑ SOIL BORING g ` J ' ❑DESTRUCTION; a F f. INTENDED UiE TYPE OF WELL / CONSTRUCTION SPECIFICATIONS \ (� A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ DIA.OF CONDUCTOR CASING /? D A,/ t ❑ DOMEBTIC/PRIVATE ❑GRAVEL PACK/SIZE : TYPE OF t:ASIN0IS'TEELfPVCL✓r� DIA.OF WELL CASING� D 1 ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ ~ SPECIFICATION I 13 IRRIGATIOWAa" ;I 13 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ,u MONITORING '�' ii GROUT SEAL PUMPED: D Y. ON-. CONCRETE PEDESTAL BY DRILLER: Yea ❑No S APPROX,DEPTH x LOCKING CRIESTER BOXISTOVE PIPE J S pRGP08Fp CONSTISUCTIOHIDRILLINO METHOD: MUD ROTARY Alfl ROTARY AUGER CABLE OTH Id� I 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OAOWANCES,STATE LAWS,AND RULES AND I REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SMNATIJRE CERTIFIES THE FOLLOWING:"!CERTIFY THAT IN THE PERFORMANCE E THE ,AMDORK FOR WHICH THIS PERMIT IS 166UEb,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA•' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES 3 THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORM CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,t SHALL,EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATLON LAWS OF CALIFORNIA'' GALL 24 IN ADVANCE FOR ALL REQUIRED{I�I�y]SPEOTIONS AT f2O61 4683423. COMPLETE DRAWING AT LOWER AREA PROVIDED, SJgrwd X Tltla / ' f� � 0 � � f I .' � PLOT PLAN(Drew-to Scale)Scale ^to T. NAMES OF STREETS OR ROAD NEAREST TO OR BOUNDING THE PROPERTY, Y 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, <• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. ....... � v~VtRO3 -tetY. f ApNlcedon A--Wad By DEPARTMENT USE ONLY In. .` Grout Feta..By l L � Data bate Deatru tbn Inpectlon By Pump Inapactkn By Area f Comments: h' �� Date Data ACCOUNTING ONLY: II AIOd PE COOFA FLEE INFO FACT O AMOUNT REMITTED C /CAP-" ntcUVED By _ DATE ---_ PERMITISERVICE REQUEST NUMBER 006366 Q/3 I 6 INVOICE i[ .J Y/J L/J_ {I r .,.....^ ,II ..