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APPLICATION FOR WELLIPUMP PERMIT ' —SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIas ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 4683420 nn p I /� NDNREFUNDRBLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �AI N l%11.E/U (Complete in Triplicate) APPLICATIONE WORK DESCRIBED. IS FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL TH QUN COUNTY DEVELOPMENTO RHES HAPTEEROB"D5 3 MID T E STANDARDS O SAN JOAQUIN COUNTY PUBBLIC HEALTH SERVICESNENVIRONMENTAL H /LLTH(DIVISION.COMPLIANCE WITN SAN /-�jA Cm, ZOO'• PARCEL SIZE/APNI JOB ADDRESSOR v/ F G4 �y� /y�.y'/� VI (ADDRESS • '1 ` (�, _ OWNER'S NAME �#" 3/ OC ADDRESS 'r'f N �o cc 6Gc'S/• NC+' S �P'I°N e CONTRACTOR '� J/ //1L J �f / `, ADD R�$6// C�/7C'�X�✓t ' UCX�[��9'0/ PHONE l SUB COMPACTOR /L /iRcstcc C yr" � El OTHER TYPE OF WELLIPUMP: [3NEW WELL El REPLACEMENT WELL ❑ MONITORING WELL X J ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# O DEPTH PUMP SET__FT. FIRST WATER LEVEL ❑New❑Ft.parc H.P. f�qq _ / (TYPE OF PUMP( ❑ DUT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL X LT SOIL BORING GPi O(�t-"'cC S ❑DESTRUCTION: A INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS X X, ./ ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION / DIA.OF CONDUCTOR CASING (Ta Dasa' O ❑ DOMESTIC/PHIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEVPVC NDNc DIA.OF WELL CASING /yA D ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL O SPECIFICATION MCA aS 3v R ❑ IMGATION/AG ❑OTHER GROUT SEAL INSTALLED BY ZC-A+/L` GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PIMPED:jd Y. ❑No CONCRETE PEDESTALBY DWLLER:❑Yr 0NoN19 S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Niel✓C/YI 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WRH 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK 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 FOLLOW( I A 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 CAUFO TECANT MUST 24110111je'IN ADVANCE FOR ALL REQUIRED�INSPECTIONS AT IZO814693 23. COMPLETE DRAWING AT LOWER AREA PROVIDED../ 610^aJ X r' Q_/A/l/•/¢-- Title Dau PLAT PLAN (Draw to S .)Scala •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALXS. ON THE PROPERTY OR ADJOINING PROPERTY. u 1 �^_/�,1/� DEPARTMENT USE ONLY Application AccepteE BY_�� Y`` p�A L A Date f O G L A,y Grout Iropecflon BY Dat. Pulp lrop tion By Date ------ Ostrmtion Iroluctlon By Det. Comment: I ACCOUNTING ONLY: AID# FAC# - G' LOC iXE CODES FEE INFO AMOUNT REMITTEDCHECK#/CASH RECEIVED BY DATE C POiMIT/SERVICE REQUEST NUMSOL INVOICE -�V �C�'7