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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201.388 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FRDM DATE ISSUED iCompkto in Tripl'Icats) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTAL.THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUSUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN'I ��((I �J{{ CRY_r_yy f' �{�jiZ _ ^PARCEL SIZE/APNW �ijJ�/�{ Q ' OWNER'S NAME V [J 1 j"�G IU/ilp Nr .Ykxk&a 1 PHONE*_1 O .L_I ,J f n A[HlHE66_ /s CONTRACTOR .J rr• �W AbbRESS_P�� {,,�1�7J LICar�2 PHONE mr 122-0 SUBCONTRACTOR ADDRESS UC* PHONE TYPE OF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTTORINI3 WELL t ❑ OTHER ❑ INSTALLATION WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL* _� ❑Hew❑Repels H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p {TYPE OF PUMPI ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL M 13 9011,BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION APECIFICAT10N6 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGMTEEL/PVC DIA.OF WELL CASINO p ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT1SEAL PUMPED: ❑Yes [IN. CONCRETE PEDESTAL BY ORILLFR:Ely. ❑Ne S APPROX.DEPTH LOCKING CHESTER BOXtBTOVE PIPE S PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER — f 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 DR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"t CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PE RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENBATioH LAWS OF CALIFORNIA.' T APPLICAN UST CALL 24 /UR8 N/IA�fO�V'AANCE FOR ALL REQUIRED INSPECTIONS AT F20914"4423. COMPLETE DRAWING AT LOWER AREA PROVIDE 8lprxd -4 Zt <.iWGJA a..�i Title C.7 4'�1/ULi` not. /"" PLOT PLAN tDrew to Scald Seek "to L4 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROFUSED 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSEDd/ S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WA&S. ON THE PROPERTY OR ADJOINING PROPERTY, ..E . . ---;............... . �s- :... ..:. : . : - DEPARTMENT USE ONLY Applketion Accepted By rl Date V Aram Grout Inspection BY Date Pump Inspection By Dat. �` t� Dastructien Impaction BY Dela Comments ACCOUNTING ONLY: AID! FAC* PE CODES FEE INFO AMOUNT REMITTED EC (CASH RECEIVED BY DATE PERMITISE RVICE REQUEST NUMBER INVOICE s-oL -7.2, 62 32 75 i