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APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVIL ENVIRONMENTAL HEALTH DIVISION ' P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED (Comilwe in Triplicate) i APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR 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., - f JOBADDRESSroRAPNx ZC9 �) „ (1 (2I6,_�.O'I�I •14V ,�1 CITY1-66 1 „-, PARCELSIZE/APN# OWNER'S NAME t} ADDRESS I CJD* LDD 1 +,G5z4a PHONE/ r' CONTRACTOR Au vRlolFl� 6&�,E�Virim Y✓ry,\'Tq Vic., -ADDRESS A LICK " PHONE X956-6 244- f sue coNTRAcro16 $T�R'�W-3 C-A (5 a� 1 5 ADDRESB 21 �5TA� uc r�PHONE P714 .41tg r ' TYPE OF WELLIPUMP, ❑ NEW WELL ❑ REPLACEMENT WELL qNB•WEi•1s ❑ OTHER 1 ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR �' VAPOR EXTRACTION WELL 13New❑ -IOL1 RYPE OF PUMP) Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVELO ❑ OUT-OF-SERVICE WELL�:-..r...t-i-. _.] GEOPHYSICAL.WELL:#.3-- �`+-�❑ SOIL 80RING- _ w,� . . .�,�.. >..--rte,-S�-�..-•-.-. ,�- .._ : , Bs-F- ❑DESTRUCTION: _ i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION- DIA.OF CONDUCTOR'CASING D ❑ DOMESTICtPRIVATE ..GRAVEL PACK184Z ,3: ] TYPE OF CASINGISTEELIPVC P+rL DIA.OF WELL CASING �Iz D 11PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL_ SPECIFICATION 2r=ft. 40 _ R 13IRWGATIONlAG ❑OTHER GROUT SEAL INSTALLEDppBY T GROUT BRAND NAME I E' MONITORING ®® GROUT SEAL PUMPED: 13 Y.r❑No CONCRETE PEDESTAL BY DRILLER:❑Yea ❑Ne S' APPROX.DEPTH L430 LOCKING CHESTER BOXISTOVE PIPE S. PROPOSED CONSTRUCTIONIDWLLING METHOD: MUD ROTARY AIR ROTARY -- AUGER 'L CABLE OTHER '! I 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 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 SUBCONTRACTING 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.' E APPYCAN UST CALL 24 URS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091468-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed x Title3 Data PLOT PLAN[Drew to Scala)Scaie 'to I i 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED i 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 U. 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. _ - ... ., ' f . - .: - . .... . ... . . :.. DEPARTMENT USE ONLY OD Application Accepted By Date IP ` Aten� Grout Inspection By Date Pump Inspection By pate t I Destruction inspection By Date Comments' _ 1 1 d F ACCOUNTING ONLY: AIDN► FACX i PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PERMITISEFVICE REQUEST NUMBER INVOICE