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APPLICATION FOR WELL►PUMP PERMIT SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION h L HEALTH P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 55201 T.; (209) 468.3420 NOF!-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED= 23 (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 DEVELOPM TITLE,C APTER 9-1115 3 AN THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# �L.CI `fLr+ �' CITY PARCEL SIZElAPN# OWNER'S NAME r �- ADDRESS�>��L.� PHONE#25Y CONTRACTOR �,.[.� ADDRE66P ''J�' L•w,c- i3�`7"-uc�i6/( I'7 PHONE+e 239-IV�, r� SUB CONTRACTOR ADDRESS UCO PHONE# TYPE OF WELU'UMP:i ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J hAlyl.�A,L�/>> ❑New 1:21Repair N.P. DEPTH PUMP SET (.1 0FT. FIRST WATER LEVEL (TYPE OF PUMP) 11OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# 11SOIL BORING B 11 DESTRUCTION: �1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS AN ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 1A 14 DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING (17 �( D(. ElPUBLIC/MUNICIPAL 13 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R`+l ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea [IN. CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 5 PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER N c I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION 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: 't CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMrr IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA..." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091 488-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SlOned X &? &2�I -,� Title (�¢�fm.t�-�/ Data i PLOT PLAN(Draw to Scale)Scale .10 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. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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. ..... S ....i....... ..... .. .. - ........... .... .. .. .. .. i . Ny rt o _ < . .. _ .1995 10 . :. AQUAERV . .__ ICS �S SAN JC - VI nU�LIC HEAL? tN RONMEN AL;H ACTH DIV SIOM DEPARTMENT USE ONLY Applioetlon Accepted By Data Area Grout Irnpectlon By - Date Pump Inspectlon By `- Date Destruction lnopectlon By Date Comments: ACCOUNTING ONLY: AID# FAC/ PE CODER FEE INFO AMOUNT REMITTED I CHEC ASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 5aroo . o� �(03� 11�lvtlm- �rISI�J �" - h o)