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APPLICATION FOR WELLIPUMP PERMIT ` !s SAN JOAQUIN COUNTY PUBLIC HEALTH SEkv ttS ENVIRONMENTAL HEALTH DIVISION P.O. BOX SW 304 EAST WEBER AVENUE:, STOCKTON, CA VaNj- ' � (209) 489.3420 - NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete IN Triplicate) APPLICATION 1S HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 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. JOB ADDRESSIOR APN!_. 434E FP, �..I anf 1 C T CITY c ,aC-K `O rV PARCEL SIZEIAPNI OWNER'S NAME CA ADDRESS 00 • I3 Wb . GLC✓✓DAL-c PHONE# AIR—9D CONTRACTOR C9 l9Z.i 'i7Jr/G✓a tsY) AvF— ADDRES8 (A LIC# PHONE! a/n¢yS3-73c 1g' 27 zr% SUS CONTRACTOR ADORES! PHONE - D h 7g TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ® MONITOR4NG WELL# I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p TTYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING g DESTRUCTION: MWI I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION! A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION INA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA,OF WELL CASING D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ FRRIGATIONIAG 110.THER GROUT SEAL INSTALLED BY GROUT BRAND NAME >: ❑ MONITORING GROUT SEAL PUMPED- ❑Yea ❑No CONCRETE PEDESTAL BY DRLLER:❑Yes ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIDrgWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HERESY 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT to ISSUED,1 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 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." T APMJCANT MUST CALL 24 HOt11R IN ADVANCE FOR ALL REQUIRED INSPECTION**.ATT�1201111 4q-3423. COMPLETE DRAWING AT LOWER AREA PROVIp 0.q Signed X - — TltlQ.D V �Ci,� €a C LC .a IS� Date V z/ PLOT PORN [Draw to Scale)SaaFe 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OA 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 PROPERTY. . rr H FO 5TT-r- P LS DEPARTMENT USE ONLY Application Acoopted By Dete25 Area w Grout Inspection By Date 2 Pump Inspection By Date Destruction Inspection By A.Lw— bete 1`J Commentr: VV 7 f Yv 0 v- dA W t o�� UL ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICABH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE � 13� N1Q b