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APPLICATION FOR WELL/PUMP pERAF'" SAN JOAVIRO COUNTY PUBLIC HEALTH SCti,rJCES ENVIRONMENTAL HEALTH DIVISION P Q BOX 38B, 44b N" SAN JOAQUIN ST,, STOCKTON, CA 96201.388 (209) 488.3420 r NON-REFUNDABLE PERMIT EXPIRES I YEAR FROA11 DATE ISSUED I APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COU i JOAQUIN COUNTY DEVELOPMENTCOUNTY Fpq q (C9IRAISb in Triplieat.) TITLE,CH PERMIT To CONSTRUCT AND/OR INSTALL I CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COU THE C HI DESCRIBED.THIS APPLICATION IS MADE IN COMP[IgNCE JOB 4OORESSroR API* f 6865 (�14WN COUNTY HEALTH SERVICES,ENVIRONMENTAL HEALTH I DIVISION.OWNER'S NAME 114 CAILE_o O W�H SAL ` ' M►Kf` !vl c(,A? A 4-{,q�1 CITY STaCa�-1- CONTRACTOR V 4- W pJ2 11 ADDRESS 7 O 'p,�-, S�I PARCEL SIZE/APNI SUB CONTRACTOR �7 IV` ADDRESS r.O.$SI 171D V 1ST? Q49H_S}�1]nn�PHON *5-Z4-1 ADDRESS uCx '` P=-�}��i TYPE OF WFLL/PUA„tP. ❑ NEW WELL uC PHONE N��` ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ OTHER ��., 11 Now 11 © CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# (TYPE OF PUMP) Repair H.P. DEPTH PUMP SET FT.❑ GEFIR ✓ ❑ OUT-OF-SERVICE WELL O GEOPHYSICAL WELL# ❑DESTRUCTION: ST WATER LEVEL SOIL BORING B INTENDED USE —�--� TYPES OF yygL CONSTRUCTIom SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM TI D A ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE DIA.OF WELL EXCAVATION T� DIA.OF CONDUCTOR CASIN N TYPE OF CASING/STEELlPVC I� O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DIA.OF WELL CASING O DEPTH OF GROUT SEAL s G I SPECIFICATION ❑ IRRIGATION/AG OTHER R GROUT SEAL INSTALLED BY- MONITORING PI PT GROUT BRAND NAME.�.I ��/1�j�Tr MONITORING E O� GROUT SEAL PUMPED: �J Yaa ❑No CONCRETE PEDESTAL BY DRILLER:❑Vag ❑No s APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE_ '{ :/� PROPOSED CONBTRUCTlONJDWLIJNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Tl—< T $ 1 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 ANO 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'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFO ANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." T APPLICANT USTkmJ24 IN ADVANCE FOR ALL REQUIREDrINSPECTIONS AT 120914004423. COMPLETE DRAWING AT LOWER AREA PROVIDED Signed X Title lJ u1 S'r' Data (=-&N. 1 PLOT PLAN(Draw to Scala)Scala '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 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. A se'$ -s�C) Tv- DEPARTMENT USE ONLY I n Application Accepted By Data �✓ AI's Grout Inspection By Date Pump Inspection By Data Destruction Inspection By Date ✓ � I Commentshmzwlit4 A^,nl Y*�U Jam Ali ACCOUNTING ONLY: AID* FAC# PE CODES EE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PEN IT/SERVICE REQUEST NUMBER INVOICE