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APPLICATION FOR WELLIPUMP PERMIT (CU KA! I y L JOAQUIN COUNTY PUBLIC HEALTH SERVICES O ENVIRONMENTAL HEALTH DIVISION z�s P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468-3420 NONREFUNDABLE 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. JOB ADDRESS/OR APNAp/� SI Q]�) / j O 6 ,� 2� CITY U h�C:l'r'� PARCEL SIZE/APNN OWNER'S NAME Q(.\ V� (1 'L y\ _(� ADDRESS- d PHONE C0NTRACTO R� 1 I(� if 4D� ) I 'i y\'r ADDRESS_ (7 �-/-��L1cN 2 ,3/ n PHONE X_ l.!_( R 27 SUB CONTRACTOR ADDRESS UCX PHONE car TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL t ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL X J New❑Repair H.P. _ DEPTH PUMP SET'tQ�FT. FIRST WATER LEVEL_. D` TYPE OF PUMP) 0 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL• ❑ SOIL BORING DESTRUCTION: VTENDED TYPE USE CONSTRUCTION SPECIFICATIONS I INDUSTRIAL ❑OPEN BOTTOM A DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 0 7 DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASING D PUBLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME 7 MONITORING E GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yep []No S PPROX.DEPTH LOCKING CHESTER BOX/STOVE PIP£ S N RO POSED CONSTRUCTION/DRIWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Tn 4EREBY 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 i :GULATIONS 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 # AIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES �E FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF 1 >LIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)4883423. COMPLETE DRAWING AT LOWER AREA PROVIDED. II tined if in/\ ./ .h:h� ��_ r I Title Date L PLOT PLAN (Dr to Sul.) Scale 'to O NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 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. 2 _. _._... a _. .... .. ..... ...... . .. ........ ........0 .. r . PAYMENT. RECEIVE[} I c u' DEC : 12 1994 SAN J jhQU i N 1 I TY PUBLIC HEA!TH ;r+CrS _ _ ENVIR, ^