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APPLICATION FOR WELLIPUMP PERMIT { SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j ENVIRONMENTAL HEALTH DIVISION P 0 BOX 368, 446 N. SAN JOAQUIN ST., STOCKTON,CA 55201.388 12091 .460-3420 r- �t"LI'" O OA PERMIT EXp"'S 1 YEAR FROM OATf ISSUED ! �u a C (COMPION in Triplicate) p APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COU FOR PE IT TO CONSTRUCT AND/Oft INSTALL THE WORK DESCFiIBEO.THIS APPLICATION IS MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APIlf S�7 Q,., CITYJl'W! c(!l�V fi �� PARCEL SITEIAPNa_ �j �/ OWNER'S NAME ✓ 6,2 �/ al� ADDRESS_ .l�j T �/ fiCi&7e�07r/d � PHONE# ' CONTRACTORlyL�+L SUB CONTRACTOR ADDRESS LIC# PHONE i TYPE OF W£LLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL if ❑ OTHER - �� ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# lo.lr .CJ Naw Ieair H.P. DEPTH PUMP SET0_�T. FIRST WATER LEVEL�� p - (TYPE OF PUMP) ^^'– ( ❑ OUT-OF•SERVICE WELL ❑ GEOF44YSICAL WELL# ❑ SOIL BORING g ❑DESTRUCTION- INTENDED USE TYPE OF WELL CONSTRUCTION SPECtHCAT10N5 A ❑INDUSTRIAL �13 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.Of CONDUCTOR CASING _ D ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEL/PVC DIA.OF WELL CASING—--. '� D ❑ PUBLX:IMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION 4 OTHER S 13MONITORING ❑ GROUT SEAL PUMPED: [3 yo. ❑No CONCRETE PEDESTALBY DRILLFR:❑Y. 13N. / S • APPROX.DEPTH 2 nbLOCKING CHESTER BOXMTOVE PIPE - S PROPOSED CONSTRUCTIONAMULUNG 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 AND + a REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CEFTTINES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH ll�' THIS PERMIT IS ISSUED,I 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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIIONAN'a COMPL TION LAWS OF CAUFOANIA." CANT MUST C bT FRO N ADVANCE FOR ALL REQUIRED INSPECTION$AT(20aI4!@J423. COMPLETE DRAIMNG AT LOWER AREA PROVIDED. Sllned X Tltle_�� _-_ , Date r PLOT PLAN(Draw to Sc"Scale •to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 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. S"WCTURES INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY. .. ..: YEN ....... F ............ ... a1995 ciIC �{:... .- ,Q. J I'8 � 1C'4EA .. b :. : ... .. .... . �'A EALT H L7rVISir�r` .. + .... .....>.. . .. 1 . . .. ` �� ........... ........... ....... . ..: ...... .......... :... .... ... .......... .......................... .. . .... : . ........................................... . �.... 1 ::� �":: : 'I ............ _ ....................... �. . ...