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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 (Complete in Triplicate) 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 -9-111 55.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# �l"TZ C• fZ 1 rI K-� CITY�I-A W E- P �j }� PARCEL SIZE/APNX 5-f- OWNER'S OWNER'S NAME'1 LI L—L7--1 LE7 fy ADDRESS ?42- 0- P-O I�I P-D PHONE#963-I I�60 CONTRACTOR ADVA NC D �C[J��V(F•t/�JI/��v , IKJG• ADDRESS IL.«W Mlt2l ft (--N *4 LICK �2 ` PHONE X-I�-626 SUBCONTRACTOR T tI[2(� LIN E / ADDRESS�U C.• R DTDY�'D L.�1 A,ICN 2 PHONE,M q-,1.-6z64 � JR-lA1 ►G-Gly` �7I sD ��,`` TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL El MONITORING WELL# XiJ OTHERI�WP'YJ ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL. ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS{' ` I A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION IW/A. DIA.OF CONDUCTOR CASING ry/� D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC K44 DIA.OF WELL CASING N/A p D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 10I SPECIFICATION ,�I,V./A B ❑ IRRIGATION/AG El7�OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E IDNTNI(.9 F-607LA-1 0 E JJ/MONITORING GROUT SEAL PUMPED: ❑Yea A3N. CONCRETE PEDESTAL BY DRILLER:❑Y. [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE � S /' PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER L/GLJPP�02j�` 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:'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 SUB-CONTRACTING 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 CALIFORNIA.-__ E APPA UST CALL 24 IN ADVANCE FOR ALL REQUIRED IN�n/aS,wPECTIONS ATT11209911t'4"-34,.2�3/COMPLETE DRAWING AT LOWER AREA PROVIDED. Sipr»dX Title ?)" ��V�l/WVZGy 7— Data 7OJ�� 7� i PLOT PLAN(Draw to Scale)Scale 'to 1. NAMES OF STREETS OR ROADS NEARES46 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 6. 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 By ��!'v - r �' vim) Date Area ]j i Grout Impaction By "7 � L Ll t� Date Pump Inapectlon By Date Destruction Impaction By Date Commenta- ACCOUNTING ONLY: Al.. FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK./CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE It C) ,�