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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAGUIN ST., STOCKTON,CA 96201.388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED IComplate 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 P�IBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNN ��1 i/ //1 It/C�L� CITY ��'.�,c,/ ) '^ PARCEEL SIZE/APNN .-�—�,l[pJ WC"ec, OWNER'S NAME I ADDRESS /�� j�I/IL _f 4l'1ccc/l-C/ CONTRACTOR//(�'7.y��f I rS ADDRESS( I 7 /! o-c— P-4. UC#67P(j7} PHONE#�S -�/�f_�S' SUBCONTRACTOR ADDRESS UCN PHONE TYPE OF WELL/PUMP: _t2LPEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL N ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL' ✓ ❑New❑Repair H.P. DEPTH PUMP SET Fr. FIRST WATER LEVEL O (TYPE OF PUMP) -- ❑OUT-0F-SERVICE WELL ❑GEOPHYSICAL WELL N ❑ SOIL BORING 8 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑INDUSTRIALOPEN BOTTOM DIA.OF WELL EXCAVATION G-/' 9�y DIA.OF CONDUCTOR CASING D ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING `A� L� D C ,__..� ❑Cyy PUBLIC/MUNICIPAL ❑DRIVEN DEPrH OF GROUT SEAL SZ7 SPECIFICATION R ;:MJRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY1J�.(��--(7-(I"�r''e(I L S GROUT BRAND NAME �0��•.'.F�'H.,��-7"''' E ❑MONITORING GROUT SEAL PUMPED:❑1 G6. CONCRETE PEDESTAL BY DRILLER:❑Y-mare S APPROX.DEPTHVi'✓�/y..��>// LOCKING CHESTER BOX/STOVE RPE 5 PROPOSED CONSTRUCTION/DRIWNQ METHOD: MUD ROTARY J< AIR ROTARY AUGER CABLE OTHER 1 HEREBY 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. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 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 CERrIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA".' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120914 3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slanea X (/LTL, V ti�n�F l��-s Title �w I 1 1P 0 Dae1C� PLOT PLAN IDlew to Sul.)Sc I "to 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. 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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. I Al c< L62 k, /C 3 �- �kv' e . ''�,, 4 ait l _ARTMENT USE ONLY Application Accepted By / Date G Aro Grout Impaction By Det. G^ Pump Inco Im.By Oate Dmac tr tion Imption By Date Comment.: ACCOUNTING ONLY: AID' FACT 1 EE INFO AMOUNT REMITTED CHEC '/CASH RECEIVED BY DATE PEAMITISERVICE REQUEST N—SM INVOICE zsr o �s� sl 3