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APPLICATION FOR WELLIPUMP PERMIT iN JOAQUIN COUNTY PUBLIC HEALTH SERVI[ ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 95201.388 (209) 458-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICamplate in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPUCATroN 15 MADE IN COMPIJANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TRLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOS AODMSSIOR APN# j I _ CITY PARCEL SIZEIAPNN—I/-L- OWNER'S NAME ADDRESS ONE#IC _ L_ L 4'vd� CONTRACTOR ADDRESS'17' UCxL--Ck GIU,iLPHONE*4IC44—, SUB CONTRACTOR '" ADDRESS UCd PHONE I TYPE OF WELLIPUMP:' ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTrORING WELL 4 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 J ❑Now❑Rapeit H.P. DEPTH RUMP SET FT. FIR WATER LEVEL 0 [TYPE OF PUMPI —r❑ -0 �/ OUTFSERVICE WELL � [3GEOPHV5iCAL WELL# 8 �- UY•DESIRUCTION: �"✓^� 'OYE VT lM�' ^� I INTENDED US£ TYPE OF EC WELL CONSTRUCTION SPIFICATIONS R ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 0 ❑ DOMESTiC/ VATE ClRAVEL PACK/SIZE TYPE OF CASINIWSTEELIPVC DIA.OF WELL CASING D PRI ❑ PUBLFCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG [3OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Y. ❑Na CONCRETE PEDESTAL BY DRILLER:❑Yaa ❑Na 8 APPROX.DEPTH LOCKING CHESTER SOXISTOVE PIPE I/ S, PROPOSED CONSTRUCTIONAMIJUNG 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 FOLLOWWG: '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 SU"ONTRACTtNG 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'a COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL.24 HOURS IN ADVANCE FOR ALL REQUIRED INSP6CTIONa AT=914484%423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Si4rod x Title Orta PLOT PLAN{Drew to Sada)Sola —"to _ I. 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,GIVINQ DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS W"IN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ........ .... .. ..... 1 . I:.. V-.@. W... ' .t� .. -- .. ... .. ... PA......:... _ .. . ... .., ... ... Q :.. ....... ..... . .. ... v1- Ii - [i- _ .. .. .. .. .. oT'E ... TT 1.