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APPLICATION FOR WELLIPUMP PERMIIe SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON. CA 86201.388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICampMtE In Triplicate} APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIINCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER B•1115.3 ANBD`THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIONMENTAL HEALTH DIVISION.. JOB ADDRESSIOR APNI 1 �-+ M D% CITY }}��PARCEL SREIAPN#�� -TMeOWNER'S NAMi. },� �- %�p VA�CW�+ ADDRESS yL PHONf t CONTRACTOR ` 1�prr}►�'LJU�b ADDRESS 6 l� c/ PHONE �1 SUB CONTRACTOR Q r�G�LT Ll � �+^"'1'� •��'FI L✓ ADDRESS 6 d M CI J PHONE aMM TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL 6 . � ❑ OTHER ❑ MSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EIRRACTN)N WELL I J ❑Naw❑Rapalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O TTYPE bf PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL P SOIL SORIN3 atB Q DESTRUCTION: INTENDED USE TYPE OF W,1L CON19TRLICTION•PE CIFlCATIONS A ❑ INOUMWAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISI2'E TYPE OF CASINGfSTEELT VC DIA.OF WELL CASING D ❑ PUSLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL BFECIFICATION R ❑ I R KIATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E A;IMONTTORING GROUT SEAL PIMPED: ❑Yr ❑No CONCRETE PEDESTAL BY DPILLFR:Ely- ❑No 5 APPROX.DEPTH _ LOCKING CHESTER/CTIOSOXASTOVE S PROPO4M CONSTIRNIDMILNO MFTWO: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOIRN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWNG:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFIC FOR WHICH THIS PERMITJS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIIING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLO G: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORIOMAM'NI COMPpYATION LAWS OF CALIFORNIA. THE CA T CALL 84 HOURS IN ADVANCE r4M ALL REQUIRED INww"ONS AT Q001 46*-M23. CGMIPPLiYETIEE DRAWING AT �7if1�t_f1�b PRD%A i D. Slprrdx `Tttk ti'+u1Y1M�Vtil]IL� PLOT PLAN ID m to Swlel Scala 'to 1. NAMES OF STREETS OR S NEAREST TO OR SOUNDING 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 RAMS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. : uvv t `;> ... UIE ONLY {/(� x'77 APPkwlon Aeoaptad By i Date Grout Impaction By Data_,jL�aM Pu mpaetlan BY Data Drtnntian Itipaaden By. Pyta Command: ACCOUNTING ONLY: ANO/ FAC/ /TIQ PE COCE'a FEE INFO AMOUNT REMITTED CHBCKPICASH RECEIVED BY DATE REQUE&T NUIM1136i INVOICE -!o 00 6