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APPLICATION FOR WELLIPUMP PERMI" SAN JOAQUIN COUNTY PUBLIC HEALTH SERrr,,ES ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete 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 COMPLIANCE WrTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. C�-�� JOB ADDRESSOR APN135 Z 7S H I UFS WAY 3 CITY\J E R N A LIS PARCEL SIZE/APN1 Z-2 S 1 11 1 (-9 is . C�:NIPNIVy �S Z�S HWY -33;yF_l'JJA� <, `PHONEIZ�C• OWNER'S NAME _ / AoogFss 'M ;A I,� -I CONTRACTOR V rVJ L71�iLLi NL', I►.LL- ADDRESS �9I hiCJIS7�;l�"�`I5 U11 C, NE PHONE-M-Z''S SUB CONTRACTOR ADDRESS LIC# PHONE J TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL 1 ` ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# (TYPE OF PUMP) 11w 11NeRepair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# OQ SOIL BORING .3 g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS pp A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION F" ,r DIA.OF CONDUCTOR CASING y- D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC ��'CN:C}l^. F�l� DIA.OF WELL CASING ' 2-.G" D ❑ PUBLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL Y^ p SPECIFICATION . 4c) .�,,y v R ❑ IRRIGATION/AG MOTHER GROUT SEAL INSTALLED BY 1 "��.W�if I 1I h GROUT BRAND NAME f4 EAr Cr EFAVIY E '\ MONITORING GROUT SEAL PUMPED: KY. ❑Ne CONCRETE PEDESTAL BY DRILLER:JOYes ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE_ S PROPOSED CONSTRUCTION/DRILLING 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'&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.' H APPLICANT MLI&T C 24. IO URS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1"614SS-S423. COMPLETE DRAWING AT LOWER AREA PROVIDED. /A Slpned X ' ! _� Titlet Date l' 1c /\ PLOT PLAN [Drs to Scale)Seals '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. ... _ VS CAW 1 "Y A 'CF WTAir_ .. : . �. ...: _. .. JV-- . h ...:. . . 3 ...... ._ ...:. _.. _'.... ......:.. _.__: ......... ......... ................ ...................:..... tr, "✓C............:......�......' i ( �_1 , DEPARTMENT USE ONLY Application Accepted By / Date Grout Impaction By Date Pump Inspectlon By Date- Destruction abDestruction Impaction By Data Comments: ACCOUNTING ONLY: AID1 FAC1 PE CODES FEE INFO AMOUNT REMITTED C /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE