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APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVW ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TTiplilli l 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 WITR SAN JOAQUIN COUNTY DEVELOPMENT`TITTLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 22.1— 141 .0L/ 1-Z I �IDO�OrI r CITY M�•� y�� PARCEL SIZAPNN JOB ADDRESS/OR APN# ) U 1 7 G 1 N 4/6 S OWNER'S NAME17o R IMA TL r -2--,Pte,gxpc lc,-,l`'e SU(s'A(L gDDRESS�O �� I- IV��`1/" PHONE N Z J�� CONTRACTOR �`C��' _—`�—• ADDRES6 ��1Ci�V HIS LION PHONEN �� [' .{�� S P��-79 ADDRESS ��V LICN 12 PHONE N�V/I SUBCONTRACTOR TYPE OF WELUPUNIR ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL N ❑New❑Rap-ir H.P. DEPTH PUMP SET---.FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) IL BORING B 13OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑DESTRUCTION: zcll 11 A INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �� .O L/ 1 t DIA.OF CONDUCTOR CASING �/}� O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/P 1V C N-(y DIA.OF WELL CASING R ❑ PIBLICR.IUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL N ERT �-�+ •-v r SPECIFICATION 1 �^-r-- GFTOII'f SEAL INSTALLED By �T�«M_ GROUT BRAND NAME N /T E ❑ IBGATION/AG OTHER [I Yea No S �J( qf^!I�pu�� GROUT SEAL PUMPED: ❑Vr [IN. CONCRETE PEDESTAL BY DRILLER: ' MONITORING,{TYT�IJ S APPROX.DEPTH_a ' LOCKING CHESTER BOX/STOVE RPE/ RY CABUE OTHER PIIOPOSED CONBTRUCTON/DRIWAUGE NQ METHOD: MUD ROTARY AIR ROTARY 7 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF HE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSEU AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMR IS S D, SHALL T PLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOW G: "ICE FV AT INT E PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'f COMPENSATION LAWS OF CALIFORNIA. TH CANT UST C 24 HOURS IR VANCE FOR ALL REQUIRED INSPECTIONS ATT1�112"�)48834]8. COMPLETE DRAWING AT LOWER AREA PROVIDED. Title SQ �'J $1,nad% PLOT WAN IDn.to SWa)Sul- 'Io 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 1. NAMES OF STREETS OR DS NEAREST TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. OUTLINE OF THE PROPE V,GIVING DIMENSIONS AND NORTH DIRECTION. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. >-5-l DEPARTMENT USE ONLY Date I�/S Area Application Accepted By AA Grout Inspection By Date Pump Inepstion By Data Data Drtructlon Inspection By Commantc ACCOUNTING ONLY: ATO# FAC# PE CODES (FEE INFO AMOUNT R ED CtH�EC"tCASH RECOVED BY DATE PERMIT/89NICE REQUEST NUMBER INVOICE