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(1 APPLICATION FOR WELLIPUMP PERMIT •"mow �, USAN JOAQUIN COUNTY PUBLIC REALTH SERYL ENVIRONMENTAL HEALTH.DIVISION P 0 BOX 388, 445 N. SAN JOACIUIN ST., STOCKTON, CA 95201.388 (209) 468-3420 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 IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER$-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OA APNni CITY i•fL[ � 3C� PARCEL SIZEIAPNK ' OWNER'S NAME_dy p ADDRESS PHONE l��." CONTRACTOR r Q" /� /� Q ADDRESS 6 LIcrlfiS320 PHONE r zzq--,1 SUB CONTRACTOR ADDRESS LIC# PHONE X ' TYPEOFWELL&M ; ❑ NEW WELL. ❑ REPLACEMENT WELL ❑ MONITORING WELL N ❑ INSTALLATION 1-3S- WELL SYSTEM REPAIR I] CROSCONNECT REPAI VAPOR EJCTAACTION WELL i J ❑New t Repair H.P. DEPTH PUMP SET4!0__FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) A-P 0,q6 P q e6Z ' ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL e ❑ SOIL BORING 13 DESTRUCTION: � INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11j INDUSTRIAL 13 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING DS-- tz DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING DCI ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ 1RRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME EE ❑ MONITORING GROUT SEAL PUMPED; ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes ❑No S . APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S. PROPOSED CONSTRUCTIONIORIWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER (114 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANI? REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH-� THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CEKTIFLES-A THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIWIAN'S COMPENSATION LAWS OF CALIFORNIA.* THE APpUy-CANT MUST CALL ALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)408-3427. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X SUxaz-, Wl6'� Title P14�. Dete f12='Z�/ I PLOT PLAN(Draw to Scale)Soals '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 6. 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. - .., ... .. .... .. - - :: : - :. . . .. .. . ..... . . : . .. . .. . . ... � .. ... .. .. . .... .. . ... I.V . ,.. . :. . . us+yli ilk.,..,k yule !_ _F.: r!:;•p:,3 i :L•Y Application Accepted By Date xL^L Area ; Grout Inspection By Date Pump Inspection By - Date r —� f t Destruction Inspection By Date t l Commants- ACCOUNTING ONLY: AID# FAC# t } PE CODES FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE }r 11 I