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�..a/ APPLICATION FOR WELLIPUMP PERMIT ��// 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIL`�S ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comploto in Triptinto) 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 9-1111�5.3 AND THE STANDARDS OF SAN JOAQUIN COUNT�YY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN#-`, t•0 1 r• YL J +�J� CI-TYp�]-'a C.a��j'' � PARCEL SSIIZZE/A,PONJ , OWNER'S NAME ADDRESS_T,d q awl 6s (7IL)a,641 6.44 "PHONE ge�la� qf�, �y CONTRACTOR V Area /L(' r ADDRESS q Q� L�A J �Ct tf LICI 7i � PHONE 024 44 T—2(3r If SUB CONTRACTOR ADDRESS LIC# PHONE# TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELLS J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING 8 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 3� A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 7 9 IJU�1 DIA.OF CONDUCTOR CASING A�Jy� D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC N A DIA.OF WELL CASING N/T D ❑ PUBIJC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL-fD-nPYIF�L� SPECIFICATION ,rJ � .% / S� ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY LJf•��I GROUT BRAND NAME CD(LTC.Ar'� �L96"T E7 j ❑ MONITORING GROCCY SEAL PUMPED: ❑Yea RN. CONCRETE PEDESTAL BY DRILLFR:❑Yes [IN. 5 / r APPROX.DEPTH 4' ro Z6 LOCKING CHESTER BOX/STOVE PIPE ,,-� ,• • 3 �' PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY jt'• AIR ROTARY AUGER_CABLE OTHER X_ Cl 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 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 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 CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF D CALIFORNIA.;THf.APPACANT MUST CALL 24 URS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)448J423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SIpnW X Jf/VJY •/(fr Tltle Date T ^/ PLOT PLAN(Draw to Scale)Seale•to •CJ 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 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. _.. .,... -. .. .- .. ... ....__...... ......_.. _................... ... DEPARTMENT USE ONLY Application Accepted Data Area Grout Impaction By Date Pump Inepectlon By Date Deatruetlon Impaction BY Date Comments: ACCOUNTING ONLY: AIDS FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE MIMIT/SERVICE REQUEST NUMBER INVOICE