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APPLICATION FOR WELLIPUMP PERMIT
<br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION *4
<br /> S / 304 EAST WEBER AVENUE, STOCKTON, CA 95202 /it
<br /> (209) 468-3420
<br /> 4 \ NON•REFUNOARLE PERMIT EXPIRES I YEAR FROM DATE ISSUED AmR
<br /> / 3ILLI// ffl C✓ CLL ICamplets in Trip&nUl
<br /> APPLICATION 19 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN
<br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH UMSION.
<br /> JOB ADDRESSIOR APN# "' Q CITY s'f�iG3�r PARCEL SIZE/APNI_
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<br /> OWNERre NAME �!c. YG� [;'jT-ic�P ADDRESS ��'O/7 L.+�,�&,e&1 S PHONE
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<br /> coNTRAcroR � �vT cJI�v� � ADDREBe � fir� fdoc(Uc 'Y+YE{ey PHONE 370(
<br /> SUS CONTRACTOR ADDRESS UC# PHONE•
<br /> _TYPE OF WELL)PUMP: ❑ NEW WELL ❑ REPLACEMENT Mit. ❑ MONITORING WELL• ❑ OTHER
<br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL Al J
<br /> ❑New❑Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O
<br /> {TYPE OF PUMPI
<br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL itSOIL BORING a
<br /> ❑DESTRUCTION;
<br /> INTENDED USE TYPE OF WiM CONSTRUCTION SPECIFICATIONS A
<br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION y S/H. GIA.OF CONDUCTOR CASING D
<br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINOISTEELIPVC DIA,OF WELL CASINO D
<br /> ❑ PUBLIC/MUNtC1PAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION / R
<br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GRDUT BRAND NAME Sbrf/ CV///%7�� E
<br /> ❑ MONITORING °' .-�t� GROUT SEAL PUMPED: 11 Yee ❑No CONCRETE PEDESTAL BY DRILLER!❑Yr ❑Ne S
<br /> APPROX,DEPTH ICT l« ( --_�j/_�1F`e.5 LOCKING CHESTER BOXISTOVE PPE S
<br /> PROPOSED CONfTRUCTTONIbRLLINO METHOD: MUD ROTARY AIR ROTARY AUGER. CABLE OTHER
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<br /> I HMSY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND
<br /> R£OULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'f 910HATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH
<br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PER13ONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES
<br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF
<br /> CALIFORNIA.- THE C T UST 24 HOURS IN ADVANCE FOR AL1 REQUIRED INSPECTIONS AT Iml 409-u aCOMPLETE DRAVNNG AT LOWER AREA PROVIDED.
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<br /> 1. NAMES OF STREET ROADS NEAREST TO OR BOU-0100 THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED
<br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS.
<br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELL8 WITHIN RADIUS OF ONE HUNDRED FIFTY FT.
<br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY.
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<br /> - -- - - -- - DEPARTMENT USE ONLY 9 �+jtt(� -
<br /> Appticetlen Aeeepted By I SAN d"pLTl0u14TY
<br /> PUBLIG HE 1.1 S
<br /> 0100 llxpee0—ey Dots Ptlmp Inspection Sy ENVIF,ONMENTA6,gf--ALTH DIVISION
<br /> O"trmtl.n Irnpectlon By Dole
<br /> C.mmerate•
<br /> ACCOUNTING ONLY; AIDS FAC#
<br /> PE CODES FEE INFO AMOUNT REN81Teb HEC ASN RECEIVED BY DATE PEhMITIBERVIC£REQUEST NUMBER INVOICE
<br /> 42r, iz
<br /> �pc v-00,X70` :
<br /> Pub.Health Serv.-Enviro.173(1/97
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