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oosio 7 APPLICATION FOR WELLIPUMP PERMIT . AN JOADUIN COUNTY PUBLIC HEALTH SERVIL..,. ENVIRONMENTAL HEALTH DIVISION P 0 BOX 38B, 446 N. SAN JOAGUIN ST., STOCKTON, CA 96201.388 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompleto in Triplicato) 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,J'FCyHAP((\�[R 9-1116.3 A /THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNY aa J J , 1i J fJ /./yI CITU /� AItI /I PJA�RCCEL SIZE/APNI �1 '1 (�'1 1' OWNER'S NAME f 1 `1 (1Cel 'L 4 ADDRE66 p 0 2- 04 / .N t•p �"I `♦ PHONE l 1 //— /1` 7 CONTRACTOR T T_ ADDRESS 2 L�2 y F, C' n rY/' IJCN 9-7f PHONE 0 �— I SUB CONTRACTOR ADDRESS UCI PHONE TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ON_RO_RING WVELLLL 1 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR CROSS-CONNECT REPAI IT ❑ VAPOR EXTRACTION WELL N J ❑Nev❑RaD•ir H.P. � OEPi� FIRST WATER LEVEL O TYPE OF PUMP) ❑ OUT-OF �/$/�J RVICEWELL /�❑ GED(%\j'VSICAL WELL N ❑ SOIL BORING e ❑DFSTRUCTIOW l.' I� ( / INTENDED USE TYPE OF WELL A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE -❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PIMPED: ❑Y•• ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑Ne S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCT)ON/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLF OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN 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 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 CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOUR IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12OSI 484113L22, COMPETE DRAWING AT LOWER AREA PROVIDED. C SIpmE X Title Dm PLOT PLAN 1D,.to ScNel Sul. 'to per„ 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. v' 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROMSED 6. LOCATION OF WELLS WTHIN RADIUS OF ONE HUNDRED FIFTY FT, T STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. �["1 Air6Ap NO S? 2 a ,Ilcu . �r �01AA WA U pip � PAYMENT RECEIVED MAR SAN JOAQUINr PLJB3 IC HUA!Ili Esf I II f?S �I ENVIRONMENTAL H At 1H UiVlalOLg � DEPARTMENT USE ONLY Apphes ion Acoaptel BY I et. 7/( Arr z r Gmm Irop•ction By Det. Pump Impaction Byiz/ze D•t•�. Dshmtion Iropmtion By Date Comment.: ACCOUNTING ONLY: AIDN FACN PE COD" FEE INFO AMOUNT R TTED CHEC /CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 1014D0