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•' �� '�` APPLICATION FOR WELLIPUMP PERMIT "IdAN JOAQUIN COUNTY PUBLIC HEALTH SERVIbVe ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 44&N.. BAN jOAfld111F•BT.r STOCKTON, CA 95201.388 JU 4 w, bOms-t (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED I 1Complate In Triplicate) 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 JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 4 w t = T�G ��I C..� JOB ADORESSroR APN,11 t.f . "ti=r�ae�'<l,e t'�.L,LTE.Q.._ZZ'X/,Cig9ND C AvjPty 12-CJD. clTv , PARCEL SIZE/APNS OWNER'S NAME ) T PRESS p' r.h 64e. kcLIQ 7 7 CONTRACTORY 4 W W�LL��fLLJltil't ADDRESSl'C7.GD 61 YID 4°fTfa ':14LICl -7U.)901+ PHONE/ 70--1, SUB CONTRACTOR ADDRESS LICJ+ PHONE# TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR © CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New ElRepair H.P. _ DEPTH PUMP SET FT. FIRST WATER LEVEL 0 RYPEDF PUMP) - � �•y = _ * L ❑POUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL X { LJ SOIL BORING h 0 ID DESTRUCTION: jvi ,`� ►�L fir_ {y i i a T7y RTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A LJ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Z5 /I DIA.OF CONDUCTOR CASING a1zh O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELIPVCt,� y L„ DIA.OF WELL CASING ❑ PUBLIC/MUNICIPAL 1:1DRIVEN DEPTH OF GROUT SEAL Q-6 f SPECIFICATION } q ❑ IRRIGATION/AG 13OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME 1�1L-AT C-C f -+ 1 EI ❑ MONITORING GROUT SEAL PUMPED: ❑Yes [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No S+ APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE g PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 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 ANTS 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,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIE¢ THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION TAWS OF CALIFORNIA.' THE APPLJCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSP� NS AT 120514!$-342]. COMPLETE DRAWING AT LOWER AREA PROVIDED. ON BEAAa,4F 05: V*W DWI.ur�tr _ Signed X �+l.i ts:}f L A/ Title Glen L-n .�L S _ Date ' ZZ "� PLOT PLJUIE(Draw to Scale)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 5. 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. AXIo%jwfl LcVEL 0 .41 - : 3 .. __ T. - __ Ca'nc.rETe —CAS I o t• 34 _ ¢ ..... .. 1 R �--. Fg. Lr1E .-rem, 1 `4 14X(CF.034 . 14- I. 7 I164}-3 Mw—i: �+.�'. Z_}��••�.- l �ter-1^-,�-`-'� •= �;•�"@. ,.. 1.: �r - DEPARTMENT USE ONLY Application Accepted By Date Area Grout Inspection By Date Pump Inspection By Date Destruction Ins pection By Date Comments: ACCOUNTING ONLY: AID,T FAG* r. PE CODES FEE INFO AMOUNT REMITTED CHFC ASH RECEIVED BY DATE PERMITI)SEIRVICE REQUEST NUMBER INVOICE