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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complat6 in Trirliwt6) 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 JOAOUIN COUNTY PU8tJq HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADORES&OR APNJ CITYPARCELSIZE/APN6 01NNEA'S NAME ADDRESS PHONE J CONTRACTOR ADDRESS UC;i2-2IQYZ) PHONE�t� SUB CONTRACTOR ADDRESS LPC J PHONE J TYPE OF WELL.IPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITOPoNG WELL J ❑ OTHER �� ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSR-CONNECT REPAIR � 13 VAPOR EXTRACTION WELL/ � New lZRapalr H.P. (TYPE OF PUMP) O _ DEPTH PUMP Sq��FT. FIRST WATER LEVEL ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL• ❑ 801E tIOPoNG B ❑DESTRUCTION: INTENDED USE TYPE OF WELL (' CONSTRUCTION SPECIFICATION& A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING C D DOMESTIC/PRIVATE ❑GRAVEL PACKMZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑ PUBLICIAAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑No CONCRETE PEDESTAL BY DPoLLER:❑Yr []No S APPROX.DEPTH Q� / LOCKING CHESTER BOX/STOVE PIPE PROPOSED CONSTRLICTION/DAILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULE8 AN REGULATIONS 04-THE SAN JOAQUIN COUNTY. HOME OWNER OR IJCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIE THE FOLLOWIN - 'I CERTIFY THAT I E ANCE OF THE WORK FDA WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP04SATION LAWS OF CALIFO THE CANT M ALL 24 URS IN ADVANCE FOR ALL REQUIRED INSPECTTIIO'NS AT(206)446-3423. COMPLETE DRAWING AT LOWER ARE7PROVIDED _vR 5lpned X Title y ( Q S _Date j PLOT PLAN Mrew to Seale)Sule '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. EXPAN&ON OF SEWAGE DISPOSAL SYSTEMS. 9. DIMENSIONED OUTLINF8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATK)N 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. PA` HENT .. . .... .. .....<... ;..... c N�� 21 1897 �....... JOAQUINI` F1 ...... COU. c VICt?�a' .. p1 g IC.HEART ISiON.....:. ... . rEALTH NWNT H U. V1R0 - �. �. .Q Y ` `. ..... ,.. . <. �. .. , . :......:.....::.... .................. DEPARTMENT USF ONLY 1ppllcatlon Accepted By Date f /r'el Arel 17 ;rout 4tepect;On By Date Pump Itrpeotlon By D.-ILL-1 leetructlon InspeCdon By Dot. :ommente:�� '1 1� f l � .L.LPD�LI� 1��LN}0 YW/r I�C L<•�A/� � (,�/�'l/KJf� f�t-K,Q,�� , FC;p 2 I T—T ACCOUNTING ONLY: AIDJ FACT PE CODES FFE INFO AMOUNT REMITTED C_NECK#/CASH RECEIVED BY DATE PfRMITI&ERV10E REQUEST NUMBER wvO10E 5 � b 1�12ai