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APPLICATION FOR WELLIPUMP PERMIT ► JAN JOAQUIN COUNTY PUBLIC HEALTH SERV,. ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 (209) 4683420 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 WRIT 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# /G 77 7 A10W1- 4n/,O RQ, ✓/e S/�7PLOT�CITY Z yr1,1,eao PARCEL SIZE/APN# 19 j/YO-O 3 OWNER'S NAME ULf/,DE�Ti9L /f�H/L/fL �O, ADDRESS /'0- iSox' 7Z Nis��.R.O F'•¢t LS NY PHONE+r G� CONTRACTOR TRC1�v TFK -C2r¢ ADDRESS.�02 V*e 04-,e4-1/A/Prl✓IY LIC# PHONE/ `g 3 -&9 0 —J SUBCONTRACTOR S�c-�c ne�•� (C)C/�L U/l�T/UJl/ / /NL ADDRFSSa3ro5 kleriy9yyz, uc# S/ZZGO PHONE*'V637-37/Z TYPf OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repalr H.P. DEPTH PUMP SFT FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING g ®DESTRUCTION: CTR6✓7- INTENDED 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 i ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION g ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yr []No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTAUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9EBY 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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PE SUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE LLOWING: 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 CA IFORNIA,' T E APPLICANT M ST ALL,24 URS ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1201)411-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. (y�, Slpned X Tltle -7- L Date PLOT PLAN (Draw to Scale)S-1.- 1. cale 'to 1. NAMES OF STREETS OR ROADS E EST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GI G DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. 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. Lpc/iSE �vc L -- MC V DEPARTMENT USE ONLY Applicetlon Accepted By_ 61r1,.'.��. i,_ !y� Date Area Grout Irnpectlon By Date Pump Inapectlon By Date Deatnrctlon Inapectlon By Data Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE