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f APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV�S "�� ENVIRONMENTAL HEALTH DIVISION P D BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON,CA 95201-388 (209) 468.3420 I NON-REFUNDABLE PERMIT EXPIRES 1IYEAR FROM DATE ISSUED IM ICemplete 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 COMPLIANCEWiTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQU14-COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. II JOB ADDRESSOR APNO .r Y�1'0% CITYC-/� __ PARCEL SIZEIAPNX OWNER'S NAME yy 1..i ADDRESSMA —T PHONE N All �1 f CONTRACTOR ADDRESS PHONE N� SUB CONTRACTOR r + ADPRES PHONE ZA t TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL N OTHER .h ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL!_jg fir II J ❑New❑Flepalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL I� O {TYPE PUMP ❑ OUT-oF-SERVICE WELL ❑ GEOPHYSIC WELL i SOIL BORING ,� B ❑DESTRUCTION: --— --- �. '1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION6 I A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING �� O ❑ DOMESTIC/PRIVATE _ ❑GRAVEL PACK/SIZE TYPE Of CASINO/STEELIPVC DIA.OF WELL CASING �� D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION �M A ❑ IRR[GATIONJAG ❑OTHER GROUT SEAL INET-ALLED BY I GROUT BRAND NAME E MONITORING GROUT SEAL PUMPED: ❑Ya Ia ❑No CONCRETE PEDESTAL BY ORILLEA:13y- ❑Nu'6 5 APPROX.DEPTH LOCKING CHESTER BOXISTOVE I� S F PROPOSED CONSTRUOTIONIDRILLING 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 COM?ENeA710N LA4 4S OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLO NG: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19I'ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. THE CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGLARED INSPECTIONS�lLT 12091 4!93423. COMPLETE DRAWING AT�� KA PROw�rIDED. �yl� Slaned X Tltle � PLOT PLAN IDra to Soalel Scale 7, NAMES OF STREETS OR ADS 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. IM 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. IM :. .-..i.._ ---. .... ..-.-i .. -.............. ................ .._........i. .. ....... I� . II : ., :.E 'I .,..,.. .. ... h . , tlyijj - - 19-4 _. EP T LIRE ONLY Appflcatlort Accepted BY - - Date L! . `Arae Grout Impactlan By Date Put napecti n By r Date � II Deatrmtian Impeotion By I Date f Cammentr. I II ACCOUNTING ONLY: AIDX PACP PE CODES FEE INFO AMOUNT REMITTED CHECK#1CASH RECEIVED BY DATE PERMITISEiVICE REQUEST NUMBER INVOICE 3501 00 � 0 � � � a Z �Ost-ir Fax Note 7671 Date+. 1� pages1 S � TO ( From Co./Dopt. ri7 �T Co. ° Phone# ( Phone# ya Fax# [# �y. Fax# �1