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APPLICATION FOR WELLIPUMP 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 I6 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 APNN /7/(/D Cin, /�/��/20—0 JOB S� (-�T/�7Z/P(�P PARCEL 31ZE/APNN OWNER'S NAME g s�,-,PENTE'R C ADDRESS /7&70 Se 46�IeZ V& PHONE N 209 CONTRACTOR T2C--sQTC--K —«� ADDRE66,20 2- Vi7G I�-.PI//n/ P,�d UCN PHONE N GJ�3-6 g/0 C-5-7 (2o y) SUB CONTRACTOR SPCCTRv�J I=XPL O�es•¢T/�n/ //(/ ADDRESS 23�S G(//� „q-M o.P UCN .�/�2 6p PHONE#'165—q 712- TYPE /LTYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL N ,/ ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑.OUT-OFF-'SERVICE WELL ❑�GEOPHYSICAL WELL N ❑ SOIL BORING g ADESTRUCTION: �� 5.810/C Cn>f,VT 7RE1-/1E 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/STEEUPVC DIA.OF WELL CASING D ❑ PU 13LIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT ?EAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING Q / GROU i SEAL PUMPED' ❑Yea [IN. CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No S APPROX.DEPTH /) (/ 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 IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FO NG: CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'i COMPENSATION LAWS OF CALIFO NIA.' THE PPjJCANT MUST ALL MIO IN ANCE FOR ALL REQUIRED INSPECTIONS AT(2001499-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED.. Slpned X Title PLOT PLAN IDraw to Scale)Scale 'to 1. NAMES OF STREETS OR ROADS NEAR T OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DI ENSIONS 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. Lov/SE �4VL /.2s -0y X v /. . i /,a'�I�,/•�//1 DEPARTMENT USE ONLY Appllcetlon Accepted By � ''„V l Area Grout Inspectlon By Date Pump Inspectlon By Date Destruction Inspection By _Det. Comments:_ 3\� \ �� ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT R ITTED CHECK#/CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE