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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 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APPIJCATION 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. YY JOB ADDRESSOR APN.r`�'4Jc) SGI�wAf- (',N c& ( CITY I Y'A.C.iI PARCEL SIZE 2-`�'t`'Di C) 0 OWNER'S NAI— ...I-- 64-61 )-1- I, �/•1 0/ ADDRESS Gf//�-� PHONE#1. CONTRACTOR COAQ a+r 7� �IVI II�S�� f&Y1� /l// L ADDRESS �iI/lLe''1f.fJ ,((� cam � PHONE 1 5 �13y-C40t) SUB CONTRACTOR r �l \l I ADDRESS ./O�IA-vyj e. t�TJ�I �UC^ �J �I PHONE I' S10 3�3-5°0� TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL D MONITORING WELL# 1 I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL. J ❑N—❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL Ir ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p 1 - A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 8 1VAC I ^ DIA.OF CONDUCTOR CASING^ f�ON`�C� D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE( � TYPE OF CASING/STEEL/PVC SC.✓1 `i'�) PVC-- DIA.OF WELL CASING _ ,I^Ol 1 YAyV\ I D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL (0—I I I V SPECIFICATION S 61 TLJ r 0.0( I V10A SOA- ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E Q MONITORING (� GROUT SEAL PUMPED: ❑Ys ZAN. CONCRETE PEDESTAL BY DRILLFR:EDYes ❑No S APFROX.DEPTH 2-(P l ' 1S LOCKING CHESTER BOXISTOVE PIPE V S PROPOSED CONSTRUCTIONIDPoWNO 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 FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA.' ITHE APPLICANT MM-'UI,S'T[CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED IN TIONS AT 11209)488-3423. CCO{�\I�PLETE DRAWING AT LOWER AREA PROVIDED. Q`� Signed X M`� �" Y�NV Title � ` PLOT PLAN ID,—to Sul.!Scale •to - NOT Tl SC A�E� 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 E. 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. _...................._ ._...__.._..._....._....... .:._._..._ ... _._ _._ _..:........... ................__ S� Tom' : „� �I1T' ✓: u/��e��, DEPARTMENT USE ONLY 9rtc gpPliution Accepted By Date �• Ara O&" Grout imPection By Date Pump Impection By Date Destruction Impaction Bye/7,,/,/` T,,l Dete F `j/A� Comment.: / �1 tom / W •/ av r1 Imo✓- 2 ACCOUNTING ONLY: AID# FAC. PE CODES FEE INFO AMOUNT REMITTED CHECK./CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE