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APPLICATION FOR WELLIPUMP PERMIT USAN JOAOUIN COUNTY PUBLIC HEALTH SERVIJ ENVIRONMENTAL HEALTH DIVISION PA. BOX 388, 304 EAST WEBER AVENUE STOCKTON. CA 95201388 1209) 488.3420 IiI 1 NOM-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplleatal APPLICATION 18 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 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# CITY l O C -�7PARCEL SIZE/APN#,�a5 OWNER'S NAME -LJ ADDRESS ••�� R PHONE# C'Lh CONTRACTOR er ADDRESS t7��ST j LIC# PFiO E ':,TrSZV SUBCONTRACTOR EiQD G +" ADDRESS V�OIr' A� ,�LICAI 1)-(0 �PHONE� TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL '[I MONITORING WELL# r_'� � ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL/ W f J i ❑New❑Repair H.P. - DEPTH PUMP SET FT. FIRST WATER LEVEL O � (TYPE Of PUMP) - - -- .1 i . , y ❑ OUT-OF-SSERVICE WELL GEOPHYSICAL WELL I ❑ 8OIL BORING B 0DESRCTION. VCMC)1 `AC-'�dWe\? ('VW -1 �I - -- , INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION$ A 0 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ♦�LI DIA.OF CONDUCTOR CASING 11 t A D ❑ DOMESTIClPRJVATE W GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC QV e-_ __ DIA.OF WELL CASING N D ❑ PUBLJC/MUNICIPAL ❑ORIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHERGROUT SEAL INSTALLED BY GROUT BRAND NAME E r Cv Ems=+ (+�\-rnLk S5 t�(MONITORING Q t GROUT SEAL PUMPED: ❑Ver ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw ❑No S APPROX.DEPTH LI 0-' 14 '22 bClJ S LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE NWS,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 PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'�NECANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUTAED INSPECTIONS AT t2081488,/42=. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slgnad x � �,.u{�� Till,9RC]S8(7- CE5(5 4G1c5T Date 12 1111q7 r I PLOT PLAN(Drew to Scale)Scale 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 PROpOBED 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. �......�..�..> k . . 6,-.-:oma: �. . -: .. . �. �.�-- �.- r e,5 >~� . .....: Ou ........................:.... . .. .. ... ........... ...... ...... . si,�o ......:.. .:.. ..:. ..: :... ..:. .. ............. .................... .. ...:... .:.. . .... <-.. ..:..........._ .... .. . .. . .. .. ........... .... ............ .. .. :... w ,1 ,.. .... .. .. .. .. .. ............... .. ............ .. ... mow:......:......:. ..:......:..... ...... ... l� .... ...... .. ...:....... ..: tU _ :. .. .... ....:......: . ......... . rte L �.. .. �e�n Splrrrn� Sri ONLY t APvlicatlan Accepted BY��/� '-..., DEPARTMENT USE O.'L Grout Inspection By Date PUMP Inspection By Date Destruction Inspection By I Z Date Comments: _ J I ACCOUNTING ONLY: AID# FACT PE CODEJS FEE INFO AMOUNT REMITTED CMF60ASH RECEIVED BY DATE PERMIT1SERVICE REGUEBT NUMBER INVOICE SO2- 5 � �7