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APPLICATION FOR 1VELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 389,445 N.SAN JOAQUIN ST.,STOCKTON,CA 95201.388 �~ �I (2091460-3420 O 0 0SCANNED �] n NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IC6m*tm i6 Trplicat6l APPLICATION M HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANnMR INSTALL THE WORIL DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 /1T°THE STANDARDS/DIF BAN JOAQUIN COUNTY rRIBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DI Vl61p H. JOB ADDRESSMA APN* L2 .: PARCEL S12ElAPNI .7— — OWNER'S NAME w ADDRESS �G WC- C PHONE r CONTRACTOR jej&&.r,,LS ♦7��J/ !_ ADDAE66� 7 r��V 'J� �jj PHONEr SUBCONTRACTOR ADDRESS s�-'-�—�— �r PHONE• TYPE OF WELUPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL* ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL r XL Naw❑Rep.ir H.P._ DEPTH PUMP SEP' FT. FIRST WATER LEVEL f/• O (TYPE OF PUMP ' ❑01TTOFSERVICE WELL ❑GEOFHY6ICAL WFiI/ ❑ SOIL BORING r 1 8 ❑DESTRUCTION: 11C_ U'1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A C {�❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DFA.OF CONDUCTORCASING b JR DOMESTICIPRIVATE ❑GRAVEL PACXJSIZE TYPE OF CASINGISTEEVPVC DIA.OF WELL CASING D r❑PUBLICJMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION JT C7 IRRICATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ❑MONITORING GROUT SEAL MUPED:❑Y. ❑No CONCRETEPEDESTALBYDR1llFR:❑Yr ❑Ne 5 APPROX.DF1r4 �CU LOCKING CHESTER BO%lSTO VE APE S PROPOSED CONSTRUCTIONRNBWNO METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER r I HEREBY CERTIFY THAT I HAVE PREPARFD THIS APFIJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN 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 PERFOWAANCE OF THE VVOHK FOR WHICH. THIS PERMIT IS ISSUED,1 81JALL NOT EMPLOY PERSONS SUBJECT TO WORIOAAWS COMPENSATION LAWS OF CALIFORMA.'CONTRACTOR'S HIRING OR SUBLONTAACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION SIGNATURE LAWS OF CALFOFNIA.'7F GCANT MUST CALL DIMS IN ANCE R ALL REOUREO INSPECTION*AT 42061 466-aS2S.COMPLETE DRAWING AT LOWER AREA PROVIDED. BWr w X Title dere PLOT PLAN IDraw.Su1e1 See1e 't.— NAMES NAMES OF STREET$ON ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAGE DISPOSAL SYSTEM OR PROPOSED 2.UUTUNF OF TOE PROPERTY,GMNG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY rr. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALJLS, ON THE PROPERTY OR ADJOINING PROPERTY. m 65-0 . AIEN 'SEP I Iv'v TIS tiI P 1 I 7 X1,1 k nv 1 r7 DEPARTMENT USE ONLY APPlic i—Aa mtee By ._._� —. .� Datn Z- 19-S Area Z�� Grout 1rnPection BY Due Pump Impec['ier$Yz�� GtW� '��Dere J� ,�! Orxstbn Insp.crion BV Dtle J• comm«n.: AccouNTlxD ONLY: AJD* FAcr PE CODES FEE INFO AMOUNT REMITTED CHEC ICAH REG VED BY DATE PERMITI&FRVICE REQUEST NUMBER INVOICE fl6_. CL