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-� "APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICa ' ENVIRONMENTAL HEALTH DIVISION P 0 BOX 38B, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplfah) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.��CHAPTER X81-111 55..3 AND THE STANDARDS LI DAARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADORESSIOR APNr [ 25 It1/� WI! /0941 V-TlRff crY7ofoefgj= PARCEL SIZEJAPN/ a Cf OWNER'S NAME _ � PHONE!T ADDRESS IL5;T�� CONTRACTOR M&LI- Yri ADDRESSl ySW'4/ A 44.� LJC#0P4Z11--7PHO�NE ijt ?S* SUB CONTRACTORp�ff hrrA" LIC / tO PHONE 0 7 d ' _ OfGh TYPE OF WEUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL- ❑ MONITORING WELLr ❑ OTHER t ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑ Now❑Repair H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL 0 [TYPE OF PUMP) � ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL* ❑ SOIL BORING g ❑DESTRUCTION: O INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS //J A A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ f.f•I�S J DIA,OF CONDUCTOR CASINGD ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC AII A-- DIA.OF WELL CASING A11A O 11PUBLICJMUNICIPAL 11DRIVEN I DEPTH OF GROUT SEAL w_- __. SPECIFICATION R ❑ IRRLGATIONIAG ❑OTHER GROAT SEAL INSTALLED BY GROUT BRAND NAME f MONITORING GROUT SEAL PUMPED: ❑Yea ONc �— CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE g PROPOSED CONSTRUOTIONIDRRIING 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 JOAOUIN 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 WOR(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'S COMPENSATION LAWS OF CALIFORNIA." C UST CALL 24 IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091489-$423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title a Date rl� IF PLAT PLAN(Draw to ScNe)Sul '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 S. 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. 491,D . ..... t .t995 { ... ENVIIRbN .. ]AL HEALT}-{ :. ..EC?MITIS�ft'.VI�CS ... ....... '. ..... .... E ....,. ....... .........`... . ., .... _. DEPARTMENT USE ONLY -- - -�-z-- Appllutlon-Aooepted•8Y •['�� - _ .., 2 Date F.' Arae- Grout Impaction By bate Pump Ii r tion By Date Dstructlon Impstlon I Date Comments: ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 1 I