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APPLICATION FOR WELLIPUMP PERMIT,-") AN JOAQUIN COUNTY PUBLIC HEALTH SEA'.._�3 ENVIRONMENTAL HEALTH DIVISION n P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Kemple$$In Trlplillat■) 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 SAP JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH,DIVISION. y / JOB ADDRESSIOR APNN /Y�� ^--�c2 2 WCSr � Com. 1— � PARCEL BtZE/APNI.,D —tl/�2D—✓L OWNER'S NAME V SL 7 * ApORE86 �® yy,,`` �C:=a✓I/ 'VL �' +U 'PHONE I 7 CONTRACTOR — ADDRESS C r G 1 CiJQ t' VCdZ�! PHONE I Y/ SUB CONTRACTOR ADDRESS LIC! PHONE TYM OF WELIJPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL* ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL* J fTYIE OF PUMP) p I 13 N.13 Ropalr H.P. DEPTH PUMP SETFT. FIRST WATER LEVE ❑ OUT-OF-�RVICE ❑ GEOPHYSICAL WE # DSrE13 eDiL BORING U �ESTRuerION. 2-0 +0 IJWP / -9,96t .SVC ZOO ".IV�JL w1 fip t a INTENDED US# TYPE OF WELL CONSTRUCTION SPECIFICATION✓$ A ❑ INDUSTRIAL ❑OPEN SOTTOM DIA.OF WELL EXCAVATION DIA.Of CONDUCTOR CASING D i ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINOISTEEUPVC DIA.OF WELL CASING D i ❑ PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION I 11IRRIGATIONIAG 13 OTHER GROUT SEAL INSTALLED 6Y GROUT BRAND NAME 6 ❑ MONITORINGi GROUT SEAL PUMPED; ❑Yea [IN. CONCRETE PEDESTAL BY DRILLER:❑Yee []No S APPROX.DEPTH LOCKING CHESTER 8OXISTOVE PIPE S� PROPOSED CON$TRUCTIONtMLUNG METHOD: MUD ROTARY AIA ROTARY AUGER CABLE OTHER ! I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND ! REGULATIONS Of THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I S NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: CE IFY T T IN PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPI3N$ATION LAWS OF CALIFORNI AN M e C 24 a IN ADVANCE FOR ALL REQUIRE*INS TIONS AT 12001400-3422. COMPLETE DRAWING AT LOWER AREA TIFED8lgrtad X CIA TltlDa1 PIAT PLAN(Draw to Seale)Smote 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNOINO THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE DISPOSAL IIYSTEM PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS S. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF OR1E HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. V ............... ....... .......... ........ ...... . ........... 0. .......... .. :... :.. ..........:. . ....- ILI.. RF , i Q .... EfJf3L { E ' I . .,. :. IAV R001ENTAL HEALTH D!V!:.'!0,`: �... ;....: .. .. .... ....... ... ..... „_..`......... ..:.... ..... .... t DEPARTMENT USE ONLY Applleatlen Aeaepted By� Dote Area Great Impeatien By Date Pump Irnpectlen By G Data Destruction Impectlon Sy Date 7 � T Comments: /0t dO 12-s� Fr(2S �L [Ts ACCOUNTING ONLY: AID# FAC* PE CODS$ FEE INFO AMOUNT REMITTED HEC Ae RECEIVED BY DATE PE RMITIMERVICE REQUEST MUMMER INVOICE 3 �