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APPLICATION FOR WELL/PUMP PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SER& 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 n Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTPRUtCTIAND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAS JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNJ OSS /'30-L4 12-?5-1 �1 k, — CITY_I all PARCEL SIZE/APN#_Q a- L 5--I SL5•-�,� OWNER'S NAME_ /�V �•� Lit��,' J /j ADDRESS_�, G; Al'r `�/Y7/' PHONE J CONTRACTORJ[1S•f �yiti I (�1SS(JLS' ADDRESS f�IYc� `1.z�`IC) LICJ / PHONE#_5 JL"1_ SUB CONTRACTOR_�I•'` �L� �A�'/J�a �H�. /� ,� &,v + ADDRESS/.d. j �/J( OTHERLIC#�.?C7�,[J1 PHONE J�fIl-7JJ-yJ� TYPE OF WELL/PUMP: CJ NEW WELL ❑ REPLACEMENT WELL +� ;�T71!LL J �; ❑ El INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL J J New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) O 11 ❑DESTRUCTION: OUT-OF-SERVICE WELL 11GEOPHYSICAL WELL# ❑ SOIL BORING B INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ A 11DOMESTIC/PRIVATE GRAVEL PACK/SIZE 113 TYPE OF CASING/STEEL/PVC_ ,r DIA.OF CONDUCTOR CASINO ' - PUS• DIA.OF WELL CASING 2 11PUBLIC/MUNICIPAL 1:1DRIVEN DEPTH OF GROUT SEALD _ � SPECIFICATION R 1111 - IRRIGATION/AG OTHER �y GROUT SEAL INSTALLED BY��,'��C s� GROUT BRAND NAME ,'gq�' LJ MONITORINGGROUT SEAL PUMPED: 11 Yes L7 No E CONCRETE PEDESTAL BY DRILLER:❑Yw 1�No S APPROX.X.DEPTH_ .2Q LOCKING CHESTER BOX/STOVE PIPE PROPOSED CONSTRUCTIONMAILLING METHOD: MUD ROTARY AIR ROTARV� S !✓_AUGER CABLE OTHER I 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 RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 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,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUFT CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)499-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slpned X 7r_ Title_/12i Date1 • 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNPLOT PLAN(Draw to Scale)Scale to DING 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 THIN SAL SYSTEMS. 6. LOCATION OF STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. WELLS RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADDJOIJOI NING PROPERTY, l c �v��iI�QLJ Application Accepted By DEPARTMENT USE ONLY Date ( /✓ D Area Y Grout Impaction By Dete Z ZU t7U Pump Inspection By Date Destructlon Inspection By Dz Date Comments-. ACCOUNTING ONLY: AID# FACJ PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE