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APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVIL ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAH JOAQUIN ST., STOCKTON, CA 95201.388 (209) 468-3420 NON-REFIINOABLE PEAMIT EXPIRES 1 YEAR FA4111 DATE ISSUED 1Complete in-Triplicate) APPLICATION IS HEREBY 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB/1DDRESSIOR APN# ^"I Z L' ��ryT s�'7 L 1 ry= rcrrr / I Ill /P,AQRCEL S{ZEIRPNd.� 17+ l ADDRESS PHONE i IL j'7 - Z JGr OWNER'S NAME'1 C,5 r �t 4 rJ G%: "�F'- LIC# PHONE#4 CONTRACTOR -'f- {�-1✓'tLs C. �e •�'� SCLC.- ...:C— ADDRESS IP'G f, r"' -� q - SUB CONTRACTOR ADbRESSr ,�.adX �a �1�- L1C.f 8l'�` PHONE I:�^ J 7 1 ¢,�.� �y ❑ OTHER. TYPE OF WELUPUMP: �/NEW WELL ❑ REPLACEMENT WELL yoj MONITORING WELL# ❑ VAR EXTRACTION WELL N J ❑ INSTALLATION ❑ WELL SYSTEM REPAIR � ❑ CROSS-CONNECT REPAIR ❑Naw❑Repair DEPTH PUMP H.P. - SET FT: FIRST WATER LEVEL {TYPE OF PUMP) SOIL BORING �� 8 C] OUT-OF•SERViCE WELL ❑ GEOPHYSICAL WELL+� ❑DESTRUCTION: A INTENDED U6E TYPE OF WELL CON6TRUCTION SPECIFIC AT10 N8 r7 d DIA.OF CONDUCTOR CASING �� D ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_/1 OMESTICIPRIVATE GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC I%L DkA.OF WELL CASING y 0D • f) ❑ P.l1BLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL' f SPECIFICATION R 13IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY L-1`t�F'`T7► GROUT BFJ1N0 NAME ♦7G' �. 4Jd Ca-7�., / a= GROUT SEAL PUMPED:Aye* ❑No CONCRETE PEDESTAL BY DRILLER:❑Ya ❑No s MONITORING - LOCKING CHESTER BOXISTOVE PIPE - 3 APpROx.DEPTH - - AUGER_CABLE - OTHER PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY "' I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORSTATE LAWS,ANO 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,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERFiF1E6 THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO ACOMPENSATION LAWS OF CALIFORNIA.' A S7 CALL 24 URS 1N ADVANCE FOR ALL REQUIRED INNSpEC AT J2001468-3423, FE DRAWING AT LOWEERR AREA A PROVIDED. Title }rY'J //I`✓[f' _Date I �� Signed% PLOT PLAN lbraw to"at Scale 'to LOCATION OF HOUSE 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. -EXPANSION OF SEWAGEE DISPOSAL SYSTEM OR PROPOSED DISPOSAL SYSTEMS. ISPO 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. fit DEPARTMENT USE ONLY _ 4 Date Application Accepted By ' Groeet Inspection BDate 1 '- p Pump Inspection By Date y Date Destruction Inspection By Comments: ACCOUNTING ONLY: AID#' FAC# t PE CODER FEE INFOAMOUNT REMITTED CNECK#ICASH RECEIVED BY OA7E pERMITlSERVICE REQUEST NUMBER INVOICE 41 t4r -- rzs ��l 0Dq q