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APPLICATION FOR WELLIPUMP PERMIT PAYMENT ' ' SAN;JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ENVIRONMENTAL HEALTH DIVISION CIVED P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 96201.388 A*iz. 15 191116 I: (209) 468.3420 SAN JO,`"WN COONTY ,i PU®L;C HEALTH"MVICES NON•REFUItOABIE PERMIT EXPIRES 1 YEAR FROM LATE ISSUED ENVIRONMENTAL HEALTH DIVISION {Complato in TriplWts} APPLICATION 16 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPIJCATION IS MADE IN CQMP[IANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9--1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/ F�q T/^ `� �+ L�1�I h - _CITY t—(-" _PARCELS ' * OWNER'SNAME VL. {�� S ,I^V�C 1 ADDRESS i•-SCI)\ ��p �(J PHONE, CoNTRAcTOA_JT�C 1 U�Ky + i� _ _ADDRESS LXS; U!J WO— S" �J`I�JL ••`-+S NE�f Q a f(�xr+" SUBCONTRACTOR C9 �--tnf.hz= ADDRES82: W• A 12"IJCM RHONE TYPE OF WELI/PUMP: NEWWELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f _ ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ =EXTRACTION WELL N ' J { ❑Naw❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) OUT-OF-SERVICE WELL (❑ GEOPHYSICAL WELL N 13SOIL BORING IT STRICTK)N: 1 •�� l �k S }jw L LA.)1, M`^' •11 U•' � +�y��t I"W� T U �,�,``"''" I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIRCAt10N8 - A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION OHO.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE [:]GRAVEL PACKISIZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CASING D ❑ PUSUCIMUNICIPAL ❑DRIVEN I' DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER ' GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yw 13N* CONCRETE PEDESTAL BY DRILLER:❑Ys [3N. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONlDNLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER t THEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,ANDrRUL.ES ANO 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,t 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 THEWORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'*COMPENSATION LAWS OF CALIFORNIA.' THEA CA�F�M�T�CjALL X4��/171OML8 IN ADVANCE FOR ALL REQUIRED INSPECTION*AT IZOB]4".3423 COMPLETE DRAWING AT LOWERAREAPROM 'ED. slanw x L _ rltle PLAT PLAN[Drew to Scwlat SHada "to 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 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED ARILS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. .. .. "I ..... ... .I J ..... . .... ........- .-..,.. ...-,.'. -- ILL /�/I'1• (/'l �1I1/ DEPARTMENT USE ONLY 7 Application Accepted By `�v IlkDete + fq pros'. . GTout Inpwtlon Byc _ "`�� Date f Y pum Irwpectlon By - - - ..... -� - _ +wr /`�>rt "may -=.—�. ,--." '�-��(s�=•.�- /- Dote _Da1tuYlon HrwPactlan By Dot* r Y- Commwft: V 1A.11�Tr ACCOUNTING ONLY: AIDI I FACE �1 - PE CODES FEE INFO AMOUNT REMITTED CHECKEtCASH RECBVED BY DATE PERMITISERVICE REQUEST NUMBER :INVOICE ;a V4;l r7 13 � I