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PPLICATION FOR WELLIPUMP PERMIT $A, jOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN#k� Jlli L1LJi,ANt. (A-4,1 i S&L' N'h CITY _J;"L 4cm,4 n r/+ PARCEL SIZE/APN# OWNER'S NAME _1�T�� c" ADDRESS"JC/ CC'r4AGQ0RF)5 N RRA.Ah_ C,I+ Cifi PHONE# z CONTRACTOR i�'�7/'V/il��'�rW��1�,] ��IV/G�. ADDRESS'/7�CAfftjJ.- /1{l�{(., Com` i 1�al-�, LICN PHONE#'jil 9 qtr �IJ1ZQ SUB CONTRACTOR V Y pl Nc t) yNVy ADDRESSP��,X J .siWCC}il�� ` t1CN 34,jf_!� PHONE TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ' p1)P'I`V'(, ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑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 J� A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ty ! DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑A=*PACK/SIZE -#I 3 !2t7 &_I`V,TYPE OF CASING/STEEL/PVC T lit C_ DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL f W> SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY j R"I.tJE"tS GROUT BRAND NAME '"/r- Sff- ("( �'`r All r E ❑ MONITORING qq a' GROUT SEAL PUMPED: ❑Yes RN. -y.�. lCONCRETE PEDESTAL BY DRILLER:[3Y. ❑No S 91 APPROX.DEPTH I"S SLG '- L�G-`� LOCKING CHESTER BOX/STOVE PIPE v s� t�1�� S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER I, CABLE OTHER 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: ERTIFV 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.- TH CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slpned X caTltle [�—'1V r�� I�'��'t-x_ Date �� / PLOT PLAN (Draw to Sle)Sulu_'to I C) 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 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. .._ ...... .. .. .. .. .. .. .. .. . .. Mw�..... .. .. .. 1 .` d - ... ...- D-MW I ............... ........... .:.................:................ .... .... .................. ..:........... . .. .. .. .. .. .. . TL _... L.. _. __ .... 2$� ...... ......... ..... ... .. .........:.. .... .......................... DEPARTMENT USE ONLY Application Accepted By Date Area Grout Inspection By Date Pump Inspection By Date Destruction Inspection By Date Comments: k06 fvv ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY I DATE PERMIT/SERVICE REQUEST NUMBER INVOICE I