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` APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SEISES ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON,.CA 95201388 (2091 468-3420 `� 3: 17 NON-REFUNDABLE PERMIT EXPIRES 1 TEAR FROM DATE ISSUED"t t (Compkb is Triplicate) APPLICATION 19 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 SA. JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APIN+f 3 I S �.�,;,;�'Lpv ICL h-, CITY S jax L -7v\/ PARCEL SIZE/APNS / OWNER'S NAME SGS \` l.Jr I(-l`r(1.4 5 �J�v� ,�.,n�l ADDRESS 1 y- :�'7 1 L)l.? L�r�'Lc•nl G-� PHONE CONTRACTOR _ V.�'Z.' {.''. (t h` {. T-E i`�1 ADDRESS�l5 L' - [�'% C�Y a r+—�- �L4"+1�'L LICI !.-I li i., PHONE+►Vo) 313 SUB CONTRACTOR 01.15,h Ir 1t.11. ovN ADDRESS 1%'�/; I��i�- '� �• ls- llCl PHONE TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL* 11Naw C3Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL � (TYPE OF PUMP) // ❑ OUT-OF-SERVICE WELL r❑ GEOPHYSICAL WELL R �SOIL BORING CTCC�I/-t rn hit_ B DESTRUCTION: A-�-,� LC.yv-_,� L-/ INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q ❑ INDUSTRIAL ❑OPEN BOTTOM DIA-OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTMIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING C ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yaa ❑No CONCRETE PEDESTAL BY DRILLER:❑Yaa ❑No S APPROX.DEPTH LOCKING CHESTER BOX/BTOVE RPE S PROPOSED CONSTRUCTION/0I11ILLING METHOD: MUD ROTARY AIR ROTARY A BLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN AC ANCE WITH BAN JOA IN COUNTY ORDINANCES,STATE LAWS,AND RULES AN REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERT FIES FOLLOWING: '1 CERT( THAT IN THE PERFORMANCE OF THE WORK FOR WHIC THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LA F C RNIA.' CONTRACT '9 HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIE THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 18 ED,I LL EMPLOY P£RSO SUBJECT TO WORKMAN'S COMPENSATION LAWS C CALIFORNIA.' T CANT'MW7,CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPfCT10Ni AT( 1 22. COMPLETE WING AT LOWER AREA PROVIDED. Signed X '� r Title +IC.-- _ r -s!,� 1�. Date I'z, ` L PLOT FLAN(Drew Scala) a -to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PRO 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE 048MBAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS W rrMN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,A D WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ........:......:......:.................. ... .. .. .. .. 1 P. . c 1., , :... ... ... ...:. ..:.....:.. .. . ... ........: . ..:... .:. ......... ..... ..... DEPARTMENT USE ONLY Application Accepted By VA04 Date At" Grout Inspection 8y Date Pump Inspection By Data Deatructlon Impaction By Data Comments: ACCOUNTING ONLY: AID# FACT r01DES FEE INFO AMOUNT REMITTED CH /CASH RECEIVED BY DATE PE REQUEST NUNSER INVOICE Z_ 0 S�l 2 p