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APPLICATION FOR WELLIPUMP PERMIT *AN JOAQUIN COUNTY PUBLIC HEALTH SERV(* ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201388 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (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 APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE wSTAND�ARRDSOF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# 2-5-700 Chr LS mam ll o ff / CITY I rn r- I ARCEL SIZE/APNN OWNER'S NAME .�J, I,Ym1 ` �f (c��(r�' ADDRESS C�/J /el /f7 co\ /_PHONE:��Lt:J�[.YA�-I I'f'' CONTRACTOR 9 S L 4 /T.We G t G ADDRESS �/`, el �cq -x z"2 UC#490`N-2- PHONE Oct, SUBCONTRACTOR ADDRESS tws66#3LI� PHONE# fi Lt TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ ❑Naw❑Reeeir H.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL O (TYPE OF PUMP( ❑ OUT-OFSERVICE WELL 13 GEOPHYSICAL WELL# 601E BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION S DIA.OF CONDUCTOR CASING O ❑ DOMESTICR VATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING O ❑ PUBUCRAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 4 .3') , SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Nt9 GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BV DRILLER:❑Ys ❑No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE RPE S PROPOSED CONSTRUCTION/DOLLING METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE MEPARED 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 THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN&ATION LAWS OF CALIFORNIA. NT�Y/j}C/1LL1 j6110UN8 IN ApVANd FOR ALL REQUIRED INS ECTION(A 120•/))4803423. COMPLETE DRAWING AT LOWER AREA PROVIDED. C "i/// _ZC//,'�..L/L�G�?r.VAlN. .��♦�CTidt /�C d >°r D4te �J CKJ PLOT PLAN Mrto Solve)Scale 'to I. 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 OUTUNF.S 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. ON THE PROPERTY OR ADJOINING PROPERTY. .. .. aloe �a eon z v c 84 4