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� APPLICATION FOR WELLfPUMP PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIL-. EhiVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 95201.388 {209) 468-3420 NOrTtZI L-, � NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICampbte in Triplintal pR APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. / LOB ADDRESSIOR APNO (� CITY .L /. ' , ` PARCEL SIZVAFNi OWNER'S NAMEAr- ��-y/ ADDRESS PHONE x�•�5 � (� CONTRACTOR /I�C�D� // tit <—r JgoDREss_�� 1�-CCaiC UCO /fes PHONE• k SUBCONTRACTOR-- ADDRESS L,IC0�PHONE Ir.AeT �, TYPE OF WELL/PUMP: a NEW WELL REPLACEMENT WELL 1:1 MONITORING WELL N ❑ OTHER ❑ INSTALLATION /Jsp❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL ,/ I ❑New❑Repair H.P. DEPTH PUMP SETtJ�„FT. FIRST WATER LEVEL (TYPE OF PUMP) ' ❑ OUT-OF•SERVICE WELL ❑ GEOPHYSICAL WELL f 4 ❑ SOIL BORING l�DESTRUCTION: I Z I-- C /�...� -17,22 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM OtA.OF WELL EXCAVATION %�Ir DIA.OF CONDUCTOR CASING D ❑ DOMESTICIMVATE ',RAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC_y�]_! /� _ DIA.OF WELL CASING D + �❑3 PUBUC/MUNtCtPAL ❑DRIVENDEPTH OF GROUT SEAL SPECIFICATION vLC_` R J6L,IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BV �A� JJ4�GROUT BRAND NAME /❑ MONITORING GROUT SEAL PUMPED:�sr ❑No CONCRETE PEDESTAL BY DRILLER:❑Ys APT-11a S APPROX.DEPTH ._ _ LOCKING/CHESjVTER BOXISTOVE PIPE s ' PRO PO SIJ,CGNSTRUCTIDN/DRILUN6 METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER i I HEr1EBV CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE{AWS,AND RULES AHD , REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 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 SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. 'I CERTIFY THAT IN THE RFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' 'TAE VST IN ADVANCE FOR ALL REGUIRED IN*P£CTIO SAT 12MI 4ft ?a. COMPLETE DRAWING AT LOWER AREA PROVID . i Siarrod XTltle� Dm ; i PLOT PLAN IOraw to Soalel Seale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 7. 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 Fr. + STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ... ..... ............... .. .... ...... .............. ...:....... . ............. -. _ _ ...;.......,..-.-. ., .. _ - .. _ ' -. .. ._. ....... _ ... ... ...... - ..... .... ........ ..,,.... - _ ... - - ................... ............. ..........A - .. .................. ..... ......... ........... .. .............. ....... vr- .................. .............. ........... .. ... . ... .:- ................... ................ ...:. .......... ...........O - - , .... . .. �,� t� ... : .... ... ....... ...... , ............ - � ..... ........................ ......- ....... ........... ............. .;. . . J .............. : •, ...... - . ..:. ....,.. �t