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I APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9520188 (209) 466.3420 NoN•REFUNDABLE PERMIT EXPIRES I YEAR FROM HATE ISSUED �✓ 4 S�� IC$IRPlet&to Tr1pneat&1 �VVJ APPLICATION IS HERE BY MADE TO THE SAN JOAOUIH COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.T1410 APPLICATION to MADE 1N MPIIANCE WITH SAN [ JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ! ' C e I JOB ADORE88roR APN7 � �e^j SL,c.r ( rn CITY ►1G PARCEL SIZEIAPN/ OWNER'S NAME / r C_` ADDRESS r C 7 • ) PHONE>r CONTRACTOR Off{ / /(. r �C' � ADDRESS / LICA?C/t�)t1 .-PHONE I SUB CONTRACTOR ADDRE$S LIC• PHONE I TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MOHrTORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r J RYP£OF PUMP) 11 New E3 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ,`. t O r ❑ OUT-OF•SERVICE WELL ❑ OEOPHYSICAL WELL 1r Q BOIL BORING 0V IkA + f B �bE$TRUCTION 11 '� 0 r 0q- r i ,` 41 ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - vv T" G • I I 1 L A ❑ INDU&TRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF Cfl UCTDR CASING e p ❑ DOMESTICIPRIVATE ❑GRAVEL PACKI$IZE TYPE OF CASING/STEEL/PVC DIA,OF WELL CASINO 'ALO p ❑ PUBUC/MUHICIPAL ❑DRIVEN - DEPTH OF GROUT SEAL SPECIFICATION Ab 4 ,#.� �,�.►1.��} ❑ IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONTORING GROUT SEAL PUMPED; ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER Ely. ❑Ne 5 AP X.DEPTH LOCKING CHESTER BOX/STOVE Pipe ' PROPOSED CONSTRUCTIONIMEUNG METHOD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER S I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,St ATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING-.'I CERTIFY THAT IN THE PERFORMANCE OF THE WORT FOR WHICH THIS PERMIT is ISSUED,I SHALL NOT EMPLOY PERSON$SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING, '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT!S ISSUED,I$HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF, CALIFORNIA.' THE Ap LI'ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUMED INSPECTION&AT 12001 4q-9473. COMPLETE DRAWING AT LOWER AREA PROVIDED Signed X %'` Title —T_T Da1e . PLOT PLAN(Draw to Sealel"It to 1. NAMES OF STREET$OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAOE DISPOSAL SYSTEM OR PROPOSED 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMS, 4 j a. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. f I STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,'AND WALKS, ON THE PROPERTY OR ADJOINING pROPERTY, Ste, .0~ :.fi997 l S LgN 11L HEAl7Li L1NlSIO i DEPARTMENT USE ONLY APplioNbn Accepted 800 dn Date Mow Inspection By `J/� Date pn PLp.Inspection By Date Deatrtmdon Impwilon SY �C-4il-y�.+ Date 1 20 Commontc r z�1 r7- ��.rl(c(w , sfi� sfioz —,7 P- 12, ----------f- ACCOUNTING ONLY: AIDJt FACE PE CODES PEE INFO AMOUNT REMITTED CHECKITI SH RECEIVED SY DATE I'MIAITISFRViCE REOUE&T NUMBER INVOICE 91 Y 51 oUq�(`