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APPLICATION EOR WELLIPUMP PERM[ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 38% 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (109) 468.3410 NON-REFUNDABLE PERMIT EXPIRES I 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 WrTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 1y f 0'-z CITY GL G PARCEL SIZE/APNR •x O(Gl-l.'�- JOB ADDRESSOR APNN !!�� OWNER'S NAME �9 C'� // e- G I ADDRESS I//>�F�'J/L/� )f`L!l-�- .'/,� / p PHONE R CONTRACTOR CC{. f�L' _ /� �- ADDRESS! ( ['l 141-3[ s{- fl 4 E/UCHKt 1�1-1 9 PNON 67 SUB CONTRACTOR ADDRESS UCI PHONE/ TYPE OF WELLIPUMP: 11NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I 601E BORING ti B ❑DESTRUCTION: 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 L DIA.OF WELL CASING D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 4�— // SPECIFICATION q ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL SY DRILLER:❑Yee [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOV PIPE g PROPOSED CONSTRUCTION/DRILUNQ 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 FOLLOWIN I C RTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I6 ISSUED,1 SHALL EMPLOY P£g80N8 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." T C M CALL 24 HOURS IN ADVANCE FOR ALL AEGLXR iNSPEC TION$AT 1209)4411414422. COMPLETE DRAWING AT LOWER AREA PRO DE . Signed X f Tltl{'r C /v _ - >d Y.L Date PLOT PLAN (Draw to Scale)Scala to I. NA 9 F STREE�PE �GIVING S NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED — OUT I OF THE DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUYLINFS AND LOCATION OF ALL ExlsrlNn Alen pnnvnc n - -- . II I DEPARTMENT USE ONLY Application Accepted By Date Area f(/ Grout Inspection By Date Pump Inspection By Date Date Destruction Impaction By Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE