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APPLICATION FOR WELLIPUMP PERMIT ,AN JOAQUIN COUNTY PUBLIC HEALTH SERVILes ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. PN JOB ADDRESS/OR A * ,`/ CITY PARCEL SIZE/APNS h OWNER'S NAME ' I 11`_ ADDRESS / PHONER J CONTRACTOR , SS 2-' SUB CONTRACTOR 17A ADDRESS LIC* PHONE* ' TYPE OF WELLIPUMP: ❑ NEW-WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL* ❑ OTHER ❑ IN§TALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL* -6 XNew❑Repair H.P. x` DEPTH PUMP SETFT. FIRST WATER LEVEL_ p (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL* ❑ SOIL BORING g 1-1 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D DOMESTIC/PRIVATE ❑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 PUMPED: ❑Y« ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I 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 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,1 SHALL.NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS RMIT 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 iO Ute IN ADVANCE FOR ALL REEQQIARED INS TIONS AT(209)4693423. COMPLETE DRAWING AT LOWER AREA PROM ED. Slarxd� / �. l � TRT �- C Owe t PLOT PLAN(Drew to Sulo)Sole 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOC ON 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 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. .... _ .... QQrz"MFT - ....... R. -Et�l. . _ .MAY.1 & 1995. _ SAN JUAGul.4 CC)IJ JT-Y :. PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION _ P ......... . Q . ............. ... ... .... .......... ..