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APPLICATION FOR WELLIPUIVIP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, 60X 383, 304 EAST WEBER AVENUE, STOCKTON, CA 9S201,W (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplets in Triplieats) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADEIN COMPLIANCE WRIT SA JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/O RAPN//X��S^�2l�--� �a--'�� CITY_LO[>l, PARCEL SIZE/APNO�S S-,I 3() OWNER'S 04F Lt3�lj /J ADDRESS_, �OX .�Ui�lt PHONE+►,5-.Y�.�5(u-S i CONTRACTOR��S"� y�1S f /• //SSIJC/G! •: J/ / ADDRESS ) Lc Yc+- R�•y ,il S� LICA PHONE/.S S[� �SCi .S`}j. SUB CONTRACTOR.." ,/ DR,' o � ADDRESSP Oy �/6 LICN + — ; RT1 �rlO`��-I PHONE 02/(�'J�J-"I/G( TYPE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL rM WELL ❑ OTHER X ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT NECT REPAIR ❑ VAPOR EXTRACTION WELLI J (TYPE OF PUMP) Now 11 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL C ❑ DESTRUCTION: OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL A' ❑ SOIL BORING B INTENDED USE TYPE OF WELL CON6TRLK:TI ON SPECIFICATIONS ❑ INDUSTRIAL A ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �� DIA.OF CONDUCTOR CASINO 11DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE '*.3 TYPE OF CASING/STEEL/PVCD_ /b/%L. DIA.OF WELL CASING_ �r 1-1O PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ! 11 SPECIFICATION n� � R 1/IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME lJVSCI�.K L`_f MONITORING GROUT SEAL PUMPED: ElYw L�No ECONCRETE PEDESTAL BY DRILLER:❑Yee 14W. S APPROX.DEPTH_ �Q LOCKING CHESTER BOX/STOVE PIPE PROPOSED CONSTAUCTION/DRIWNQ METHOD: MUD ROTARY AIR ROTARY AUGERS CABLE OTHER I 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 ANC REGULATIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICF, THIS PERMIT I6 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.' T E APPLICANT MI:1,Pf C 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(200(4",5422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slpned X Tltle ./1 I Date PLOT PLAN(Draw to Scale)Scale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION F SEWAGE DISPOSALNRAD SYSTEMS. S. LOCATION Of STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. ..:........... ........ .. - .. .. ........ .i.._. ....i.....:. 777 I DEPARTMENT USE ONLY ��)) /t )��, 1/x•1/ Application Accepted By Date Arw Grout Inspection By. Date (p� P. .Irnpectlon By Date Destruction Inspection By Date Comments: ACCOUNTING ONLY: AID/ FACA' PE CODES FEE INFO AMOUNT REMITTED CHE /CASH RECEIVED BY DATE PERMIT/SEAVICE REQUEST NUMB Eit INVOICE dl �� t S �200� o" �_