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APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERV ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICamplate 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 ADDRESSOR APN#.05-8-/So- _S /X751 �j ,^ }-� j- CITY 1 1,11// PARCEL SIZE/APN# S Q$ ,/SCr OWNER'S NAME p•� L rltlr j ADDRESS_/. D AAI)r •3O©G PHONE# -iO-- Sr✓ -S10 S CONTRACTOR �'�/t ADDRESS_I�GG Lc3fCE ��sL'T/C Gt<'•<, LICA' PHONE#Sk-,xi �x SUBCONTRACTOR I/ t,(/ ��,y�'/ly �L ADDRESS/Cj, Rti, q/(, LIC,r7�&)9C1�4 PHONE,f/jf; 77)'•tl/C'Lr TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL L`7 MDN1 0 MVt.1�*JELL# v, ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑ (TYPE OF PUMP) w 11NeRepair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING - g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION 1,�r DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE 1J GRAVEL PACK/SIZE _ TYPE OF CASING/STEEL/PVC //�-VG. DIA.OF WELL CASING -2•^ D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ,, 3J) Z SPECIFICATION /J� R �❑ L) IIRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY URr&.< GROUT BRAND NAME llVSC•�1� E L'7 MONITORING GROUT SEAL PUMPED: ❑Yea 9No CONCRETE PEDESTAL BY DRILLER:❑Yr 2N. S APPROX.DEPTH V LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DAILLING METHOD: MUD ROTARY AIR ROTARY AUGER 1,� CABLE OTHER I HE-tEBY 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. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I 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 SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT FOUSST/CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED.INNSPECTION$AT 12091409-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X F::Lj , ( (`/..t�Lt(fl Title /i(LyG Date /2 43 ko PLOT PLAN(Draw to Seale)Style 'to I. 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 OUTLINES 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. L ... ..... l DEPARTMENT USE ONLY Cvyt ('� Applleetlon Accepted By Date 1241,5 Area P"1 Grout Inspection By Date �b Pump Inspection By (( Date Deatruetlon Inspeetlon By -Date��Jl Comments: ACCOUNTIN NLY: AID# FAC# P CODES FEE INFO AMOUNT REMITTED CHEC #CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 18 2' C L DD lzov�