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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERYH^ES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (C*mplate In Triplicate) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 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 ADDRESSOR APN# 'i S - �G(G�/ /t/c� CITY PARCEL SIZE/APN# OWNER'S NAME !-GIA 1/S (�1Lpx/-Qr ADDRESS D-7/n<y f1'I �_ PHONE) ��t— -2- CONTRACTOR_FI�'e-/ ��S /C�t� �I1 _ ADORE66__f O LJO�� M1 jrUCI_ys39G-2 PHONE) S—�QI SUB CONTRACTOR ADDRESS UC# PHONE# TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLI ❑Nen❑Repel, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) �/.�( /j� ' 1 "L ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING 8 1-1 DESTRUCTION: N IF INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D DOMEBTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE Of CASINO/STEEUPVC DIA.OF WELL CASING 0v ❑ 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. [IN. CONCRETE PEDESTAL BY DRILLER:❑Vee ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 5 < PROPOSED CON*TRUCTION/DAILUNG METHOD: MUD ROTARY AIR ROTARYb 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 RULER 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 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'*COMPENSATION LAWS OF CALIFORNIA.' THE MIPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPPCT)ONS AT(2.08))488-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. 8lpned X Q Title PL 11,,,I„j / PQ/�� Date / PLOT PLAN(Draw to Goal.)Scale '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 OUTUNFS 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. _ - ._ ,( t . .: ... .. ..... .: IV L _ zir .. _ ..... rnrn. ; Iv . 7C5. . . .. .:.... .. .... .. .. .. e ___: � AUG 8 _ 1996 _ i✓ ; (� . . A ...: ..• .. .. N JUAOUIN PlJ8bc HEALTH SERVICE$ f t ALTH DIV). 'ENVRDN�IENTAL Fi , DEPARTMENT USE ONLY ApplleNlon Accepted By Date Area_ Grout Impectlon By - Date Pump Inepectlon By Date Dmirmtlon Inepectlon By Data Comments ACCOUNTING ONLY: AID/ FAC# PE CODES FEE INFO AMOUNT REMITTED CHEC /CAB. RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE O `5 "�