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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SEF>,,,ES ENVIRONMENTAL HEALTH DIVISION - L7 P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTONt,CA 9MI� -388 (209) 468-3420 : - I 2,_ = 3: E7 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/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 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 ADORESS/OR APN# I�^ (,-;'Jt1 IGI% f-f CITY S/.bxL ic vt PARCEL SIZE/APN# 6_45-L14 OWNER'S NAME S t%4., \` �!r ` �1;•/ t.l.i'�S `0IY�(�c•��ADDRESS I 'y•e-� 11223 4 i.:iLj.• c►: C t r /. -PHONE I(S/'✓) t CONTRACTOR_ V_ t,'-,:T 1^,. I(r'13 -e -C�f'r�1:, ADDRESS t��(i Nr,-:' 'Ei�- MLV•+I"%L IJCXC LI PHONE ROD) SUR CONTRACTOR �: (� -�"h %`� - �n ADDRESS /J.'�/1 /i tri'): �[.••a ,�.r+;,�., l(t. LIC# PHONE 0Irl-1"Jt;-;.1 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New❑Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL c TYPE OF PUMP) 1:1OUT-0FSERVN:E WELL 1.. /❑ QEOPHY6ICAL WELL# F� SOIL BORING (R-4,4 m 11 - = 8 WL•DESTRUCTION: c-vt-,"✓ c..J/ INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTFOAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ORA.OF CONDUCTOR CASING p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASING ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes ❑Ne S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AN REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'t CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUBCONTRACTINO SIGNATURE CERTI FIE 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 C CALIFORNIA.* T CANT-1M/l$3�CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1200146111,3423. COMMM DRAWING AT LOWER AREA PROVIDED. Stoned X Title o�A, PLOT PLAN(Drew to Scale)Scale '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 S. 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. ... . .......... .F .:. •Ir .. .. ........ ... ... ... .:..............;....... I .................. Application Accepted BDEPARTMENT USE ONLY y Date 9 2 f 6 Mae Grout Inspection By Date PUmP Inspection By Date Destruction Inspection By Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT RONITTED CH /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NLIMSE R INVOICE SO Z 0 S-) Z 7 G D