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APPLICATION FOR WELLIPUMP PERMIT PAYMENT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �r ENVIRONMENTAL HEALTH DIVISION RECEIVED P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 56201.388 MAR 11 1196 (209) 488.3420 SAN j0fr 911{l �;(JUNTY NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBS It H4-I..T I.1 KIIWUS (Complato in TOPH0 %) ENVIRONMENT4 HMTN DIVISION 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 36 ds�TK PARCE Si}ElAPNN JOB ADDRESSIOR APNr ,��[ yy. ��//�J �'t'SI'.i n ,�/Ey/ab,� �S/4 �LbrG'rs �✓Y ADOf1EBB a��• 4? - �D 0 • � �PHONE �� 1-, 6- OWNER'S NAME v 22 F#f CONTRACTOR { �.A PZ-MI.�T� �� ADDRESS Y/JI 9 I -'ham-e`c. i4��a L1CI �Z PHONE�,�-,—c[ ADDRESS(- A� C"'1 2 �+S LIC# PHONE TYPE OF WELUIPUMP: ❑ NEW WELT ❑ REPLACEMENT WELL ❑ MONRTORING WELL* ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O {TYPE OF PUMP) 8 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOIL BORING : / /��fL�� Zs,, � !N[N ,[J+b+ti�7t C+� + ZxESTRUCTION INTENDED USE TYPE OF WELL CONSTRUCTION SPECIPCATiON6 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTic1mVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTFELIPVC DIA.OF WELL CASING U ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION CXJT L'�uL _ R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONfTORING GROUT SEAL PUMPED: ❑Yes [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CON3TRUCTIONIDRIUJNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 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 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 RSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOU-OWING: I CERTIFY THAT IN T WORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T NT MU C HO RN ADVANCE FOR ALL REQUIRED 1N9 TIONS AT 120914!03433, COMPLETE DRAWING AT LOWER AREA PROVIDED. SIIr11d X Title /� �Date PAT PLAN[Drawto Scala)Seals_ to T tT'f 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. �.{'--per 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. J MW-z. .... .. .... r �rar7 +✓ b � 1$��Lfllw�s 503 4feC 4crl /,Of. I leww. Aq 14"J"r DEPARTMENT USE ONLY Application Accepted By __ -__ Date i1+,Ara +�✓`�'�� Grout Irupectlon BY Date Pump Impectien By Data Destruction Impaction By Date COrtlrnMte: ACCOUNTING ONLY. AID1r FAC,I Y/} Z— Pi CODES FEE INFO AMOUNT REMITTED C Ky CCASH RECEIVED BY DATE lSHNRCE REQUEST NUMBER INVOICE (' f Jim