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APPLICATION FOR WELLJPUMP 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 IcwVl.t9 in Triplint9) APPLICATION 18 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 rSTANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN+t lW�t [� O Jf Ery l�/�/ CITY sye- `! 41 ter" PARCEL SIZE/APNM OWNER'S NAME ! + 1 'J( r �-7T� 03 O. 1/S f ADDRESS �G /VC T�- � PHONE# CONTRACTOR �-y(/t_Com-�! Z� J�..:/ C� ADDRESBgz%_/2 �. �G,. yp rj P UC139?0s15 PHONE SUB CONTRACTOR ADDRESS LIC* PHONE t ' TYPE OF WELL(PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLf OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL L00 J 11New Int RepMr H.P.�� DEPTH PUMP SET . FIRST WATER LEVEL f J O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING 8 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING D DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGlSTEEL'PVC DIA.OF WELL CASING O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION q� ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING r GROUT SEAL PUMPED: ❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea [IN. S, APPROX.DEPTH l�J r LOCKING CHESTER BOX/STOVE PIPE g PROPOSED CONSTRUCTIONAMULING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERMES THE FOLLOWING: '1 CERTIFY THAT IN THE PE RPMANCE 9F THE WORK FOR WMCH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATI LAWS OF CALIFORNIA.' T ANT MUST CALL IN VANCE FOR ALL RKOU1Rm IEC INSTIONS AT 12091 489-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SlpnW Title p! Data PLAT PLAN IDrow to Sols)Scale 'to 1, 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 PRUPELRY. . . .......y............. .:............................... ............. ... .. .. -1 *7 5 �_y..... .............t .................:............... a... .. ... ...........:..........................;..................:.. .. ....................... :......:...................... ..... .,. ....... .. , .... ...................... ._....................... . .. .. L .......PQ:�fl4�'E�1 T`.... .. . .. ....... ...... .. ........ �. ......... ... -DEC :1..5...1995. �y ihALTH S.trv��,t� U kxj .. .........i...._... , '�0 ��• ...... ...,..... .....a.... •LIr VIHIJ.VlY1 :V I riL HEALS 1 f'1 iJ1V080ION DEPARTMENT USE ONLY 7 Application Accepted By .—Date s— A �+A 31 Grout Impaction By to Pump Inspection By Gale Destruction Impaction By Date comments: ACCOUNTING ONLY: AID/ FAC{' PE CODES FEE INFO I AMOUNT RTrTpTTED HEC ASH RECEVED BY DATE POWIT16ERVICE REQUEST NUMBER INVOICE 17 40 Ll V�4 a. 5 r o 0 �'uq