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APPLICATION FOR WELLIPUMP PERMIT ` j AN JOAQUIN COUNTY PUBLIC HEALTH SERiJ ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKMN, 52 CA 9 I W + (209) 466.3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (CompNb in Tri&sts) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER S-1115.3.'AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. s JOB ADDRESSOR APN* 46 0�J r.A P^-e_ 0z1 I`j4 k� - ' T CITY S!_a:C1�(.JCJ/t `i' ---.-.---.- _PARCEL SIZE/APN* : OWNER'S NAME !-1 C LIQ /t[ C grc,,q 4,q — Tri f ADDRESS p�J0. [;yy�%a�/ S"o/S./CIlP�1fSfQ 'S, S�FiONE N S-_7 q- 71-7 CONTRACTOR !'✓ /•.��/) ADDRESS ! -Q. U;a�l 'J � Y_�,S�4UCI 70090v PHONE! C;!-,W I5 SUS CONTRACTOR ADDRESS ' LIC# F PHONE R I i TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# } € ❑ OTHER f ❑ INSTALLATION 11WELL SYSTEM REPAIR 13CROSS-CONNECT REPAIRF Ips ❑ VAPOR EXTRACTION WELL* ❑New❑Repair H.P. DEPTH PUMP SET FT. '� � FIRST WATER LEVEL i O (TYPE OF PUMP) ❑,OUT_OF-SERVICE WELL ❑ GEOPHYSICA.L WELL* ❑ SOIL BORINGII, at g F I� IW DESTRUCTION: F lv— INTENDED USE TYPE Of WELL - CONSTRUCTION SPECIFICATIONSY ;'f 'A ❑ INDUSTRIAL ❑OVEN BOTTOM DIA.Of WELL EXCAVATION I'�I DIA,OF CONDUCTOR CASING ID s ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISR£ TYPE OF CASINGISTEELIPVC ':1 hF DIA.OF WELL CASING ;`p ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL f ly SPECIFICATION 4 R s ❑ IRRIGATION/An ❑OTHER GROUT SEAL INSTALLED BY F GROUT BRAND NAME ':a£ ❑ MONITORING GROUT SEAL PUMPED: ❑Y. ❑Ne i CONCRETE PEDESTAL BY DRILLER:❑YM [IN. ;S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE ;g PROPOSED CONSTRUCTIONMAILLINO METHOD: MUD ROTARY AIR ROTARY AUGER'! CABLE (OTHER I 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:-1 CERTIFY THAT IN THE(PERFORMANCE OF THE WORT(FOR WHICH T14I6 PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR'SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY AT IN THE PERFORMANCE-OF-THE WORK.FOR WHICH-THIS PERMIT IS ISSUED,,-I.SHALL-EMPLOY PERSONS SUBJECT-TO-WORKMAN'S COMPENSATION LAWS OF CAUFOR / HE; CA T ST 24 HD IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001 4"4422. COMPLETE DRAWING Al-LOWER AREA PROVIDED. Signed X 9Title_r�G PLOT PLAN IDrow to Scaiel 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, I,F 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 FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. j ON THE PROPERTY OR ADJOINING PROPERTY. s. ... - : Ilk .II E1 -. ., I t. t: DEPARTMENT USE ONLY a Application Accepted By bate Arae Grout Inspection By Date Pump Inspection By Date FS Destruction Inspection By - Dote - Comments: .1 :t h � - Iq r _ R I ACCOUNTING ONLY: AID# FAC* PE CODES FEE INFO AMOUNT REMITTED CHECK#MASH RECEIVED BY DATE F PERITTISERVICE REQUEST NUMBER INVOICE t i. I 4 k4. i