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go-51go-�7 <br /> APPLICATION FOR WELLIPUMP PERMIT ' <br /> 'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE" <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RID, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate( <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN tJOAQUIN COUNTY <br /> {/PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> J08 ADDRESS/OR APN# / Z r rvl rvt Q��-=e 1 n ST tC") CIT/ L"�1 t/ Gfiqej PARCEL SIZE/AFYJI <br /> OWNER'S NAME , G ^dam ADDRESS PHONE# <br /> CONTRACTOR ADORERS ^^�� UCI /''�/ QPHONE R ,`t-� rte/ <br /> SUB CONTRACTOR �/� \ 1 ADDRESS /L 3 Ca � LIC#1.5/22 PHONE!' J <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> ❑New❑Repalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> (TYPE OF PUMPI <br /> ❑ OUT-OF-SERV#F E WELL ❑ GEO IVSIC AL WELL ❑ SOIL BORING S <br /> D(,` <br /> A—STRUCTION: i1�Q F y-/r L O � 4INTENDED USE TYPE OF WELL 7EONSTRUCTION SPECIFICATIONS f(`� A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION CJ DIA.OF CONDUCTOR CASINO p <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC Pl/� DIA.OF WELL CASING N p <br /> ❑ PU13LIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> IRR❑ Io 11 OTHER GROUT SEAL INSTALLED BY <br /> GROUT BRAND NAME <br /> MONITORING GROUT SEAL PUMpEpwNe E <br /> CONCRETE PEDESTAL BY DWLLERCBLY— ❑No S <br /> APPROX.bM" LOCKING CHESTER BOX/STOVE PIPE s. <br /> PROPOSED CONSTRUCTIONR7WUTNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 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 <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR NMICH <br /> THIS IT IS LIED,1 SHALL NOT EMPLOY PERBONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE f LLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF E WOW(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAW.OF <br /> CALIF NIA.' THE PPUC ANT MVST C LL IN AD CE FOR ALL REQUIRED INSPFCTIQNS AT 48eJ42.. COMPLETE DRAWING AT LOWER AREA PR....O++++V7777IDED. <br /> Blpnad X Tltle <br /> 2%7 Date <br /> -�_1'� <br /> PLor PLAN(Draw to Beata)Boal@ •to <br /> 1. NAMES OF ST ET.OR ROADS NEAREIIOn BOUNDING TLE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYBTEM On P/TOPOSED <br /> 2. OUTLINE OF THE PROPERTY,GMNO DI NSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OVTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> BTRVCTUREB,INCLUDING COVERED AREAE SUCH AS PAT108�bRIVEWAYS AND WALK6. ON THF PMpErffV On An tntuturs,pmntgwv _ <br /> ;SSSS. <br /> .. .. <br /> ;SSSS <br /> i....?... .,.. <br /> DEPARTMENT USE ONLY �/J 7 <br /> Appllcatlon Accepted By Date • / �� / Ar v <br /> Grout Inspeello By Date Pump lnspeetlon By Date <br /> Oeaw.fl.n inspection By Date <br /> Comment: <br /> ACCOUNTING ONLY: AID# FAC/ `1(0 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DA 7 PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> :356 WD <br /> Pub.Health Serv.-Enviro.173(3/96) �,f� <br />