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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SER._�S 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 (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. y JOB ADDRESS/OR APN#LI/�fiy O/yE.yS F,QD SDO Zo(//SE ,q!'� CITY�f�T//�o PARCEL SIZE/APN/�/p OWNER'S NAME �T��BY 19W CICS P-OeQ PHONE ADDRESS SOb �6�//,SG ArC: A' CONTRACTOR /iPL'gT��C—�j�i� ADDRESS .?D ZLIC# PHONE N SUB CONTRACTOR_ S/�F'L TiP�//�! ��Y/✓LO/e�T/DICT ADDRESS.?365 W,166 wd/ V4 .OX. LICX :5-122f,,$ PHONE 7 yam'S-O 7 2 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D (TYPE OF PUMP) L� ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g DESTRUCTION: —Sly r��WV/�L��L��f C7�✓T rRE/�liE INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT ;FAL INSTALLED BY GROUT BRAND NAME E ❑ MONFTORING / GROUT SEAL PUMPED: ❑Yea [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr [IN. S APPROX.DEPTH 50 LOCKING CHESTER BOX/STOVE PIPE 5 PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9EBY CERTIFY THAT I RAVE 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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERM ED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE F OWING: CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMFT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIF �NIATHE�CANT MUST CALL 24 HOUR AD ANCE LOR ALL REQUIRED INSPECTIONS /�A,T,(209)4693422. COMPLETE DRAWING AT LOWER AREA PROVIDED. 9 SIQr»d X Title /y(, - Data 5 /� PLOT PLAN (Maw to Scale) Scale 'to 1. NAMES OF STREETS OR ROADS NEAREO 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 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. L�✓isE Nye. G/lS�3T� OweE vs ,7. . 12 X: _ ......_... ..... :. ......:....... DEPARTMENT USE ONLY Application Accepted By Date ` ( `` ` Area Grout Inspection By Date Pump Inspection By Date _ Destruction Inspection By �J�N o Date' Comments: ��(✓ 0. �1✓5�l.byfi�� ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE