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APPLICATION FOR WELLIPUMP PERMIT JAN JOAQUIN COUNTY PUBLIC HEALTH SER so ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compkth in Troliests) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TRIS 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# D CITY L/'?TF//RO P PARCEL SIZE/APN#Z?0 I�D ^/7 / OWNER'S NAME l�E/9,e/✓f' I�CNTV.QL�S LTD 1400SJ /ZpApS LSV DRESS .S6 7y STo^/ER/'Ar'rE OR..dY Ci/�lA m/✓l'�HONE x S/o Qy7—Y5;10;1 CONTRACTOR �i'�F'9�F�—C,Q/A ADDRE86,2UZ zl L lJE/P(//N P�W7o LIC# PHONE A''JP10(/ 3 /'0 SUB CONTRACTOR5��%/PvNJ Lc�Y�LOiQ/gT/D�/ ADDRESS,, G(//44✓AM D.2. uc# S7 2 2 G 8 PHONE#`/6 5-9 J AZ TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New 11Repalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p (TYPE OF PUMP) Gj ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL#_ ❑ SOIL BORING g DESTRUCTION: / -Sa1�lr SAiVlJ��C:2W6 NT y/ 71eltFMIE INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING p ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG! ❑OTHER GROUI .,EAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING L 3) („/LCL L.5 / C GROUT SEAL PUMPED: ❑Yea [IN. CONCRETE PEDESTAL BY DRILLER:❑Yas ❑No S APPROX. DEPTH SO /�I<- /L LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER 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 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FO WING: 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 NT CALIF NIA.• THE PPLJCAMUST C L 24�kW V 8 IN ANCE FOR ALL REQUIRED INSPECTIONS AAT 12081 4683421. COMPLETE DRAWING AT LOWER AREA PROVIDED.^� 9 Slpned X Tltle '//�/ Y[ Date ✓ — /L—/ 7 PLOT PLAN M,sw to Scale)Scale 'to 1. NAMES OF STREETS OR ROADS NEA T 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. .. .. .. _.. /30 �%) . ...: . - \ (� DEPARTMENT USE ONLY Applicatlon Accepted By P-�L/�J i(,(� -1 Date J Ie) Area Grout 1rnpectlon By Date Pump Inspection By Date Deatructlon Irnpectlon By Date Comments:_ �\, � i ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE f�l� �' 1 d 1 q-s-y