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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 469.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITN SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 115.3 AND TIIE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI CIT'/ PARCEL SIZE/APN# OWNER'S NAME ADDRESS PHONE# CONTRACTOR ADDRESS UCI PHONE SUR CONTRACTOR ADOnFSB UCI PHONE IF— TYPE TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAln ❑ VAPOR EXTRACTION WELL# H VPE OF PVMPI ❑New❑Rep.lr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ GEOF41YSICAL WELL# ❑ SOIL BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION CIA.OF CONDUCTOR CASINO p ❑ DOMFSTIC/M IVATE ❑GRAVEL PACK/SIZE TYPE,OF CASINO/STEEVPVC DIA.OF WELL CASING D ❑ PUBLIC lMUNIC IPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITOnINO GROUT SEAL PUMPED: []Y- ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yee [IN. S APPROX.DEPTH LOCKING CHESTER BOXY,, 11E r'1PE S PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CARL OTHER 1 HE9EBV CERTIFY TI4AT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WIT(! '.V JOAQU COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF T14F SAN JOAQUIN COUNTY. HOME OWNER On LICENSED AOFNT'S SIGNATURE CERTIFIES THE FOLLOWlt, '1 CERTIF, THAT IN THE PERFOnMANCE OF THE WORK FOR WHICH T141S PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR•8 HIRING OR SUR-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091460-3423, COMPLETE DRAWING AT LOWER AREA PROVIDED. Slpned X Tltle Date PLOT PLAN(Dr to Sahel Roel. to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES 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 On ADJOINING PROPERTY. DEPARTMENT USE ONLY Appllcetlen Accepted By _ Dote Ata Grout Impecllon By Det._ P.enp Inepeetlen By Date 0-1—tlon I—peallon By Osla Cemme W ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK/(CASH RECEIVED By DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(3/96)