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APPLICATION FOR WELLIPUMP PERMIT— SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 9520188 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES I 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 S/ JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115 :3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 10 1t JOB ADDRESS/OR APNI CITU J� PHONE/ PARCEL SIZE/APN/ OWNER'S NAME ADDRESS Y �q �C(, /�ro[' CONTRACTOR ' ADDRESS �y O�L µ �UCA .�X PHONE( 7 Z�d S SUB CONTRACTOR ADDRESS LIC( PHONE#- -TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLf New❑Repair H.P. DEPTH PUMP SET FT. (TYPE PU PI t FIRST WATER LEVEL t ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 0 ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS d❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONDIA.OF CONDUCTOR CASING p t04 DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING L ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME £ ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/MILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE9ESY 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 ANI REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICI THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIE THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O CALIFORNIA.' 7114— CANT MUST CA 24 HO IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT 120{14M ��J�.�Cj.O�M DRAW1 AT LOWER AREA PROVIDED. ` �R_rd l/,,C'L^1�<'"64 - p � Data Slpned X A �� Title f— PLOT PLAN IDT to Soalal Scala 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 OUTLINFS 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 On ADJOINING PROPERTY, . ..... UUA 1 A e uU�LI�HEALTHFR�11f e :NVIf�ONMFN'A MEAL. Ia tjl�/IS 1'I — - _ I DEPARTMENT USE ONLY Application Accepted By D o Area Grout 1rnpectlon By Date Pump In.pectlon By / Dale Q lJ D—Iructlen lmpactlon By - Date Comments. ACCOUNTING ONLY: AID/ FACT PE CODES FEE INFO AMOUNT REMITTED CHECK PICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE