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APPLICATION FOR WELLIPUMP PERMI <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEES PAYMENT <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 MAR 13 tmj6 <br /> (209) 4663420 SAN JO, 'UIN COUNTY <br /> ERVICFS <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUER ENVIRONMENTAL HEALTH DIVISION <br /> (Complete in Triplicatel <br /> 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 WITH SAI <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF <br /> SA1N�JOAOUI U C 1 E LTH SER ENVIR�O}NM A,L.H,EEAL(TTH DDJ/,VM ON <br /> JOB ADDRESSOR (� 1 "' ""�"->/ <br /> //``�� ,..(' CITY i p '1 PARCEL SIZUAPNI <br /> OWNER'S NAM , c CYC /V �D'N/`C' <br /> AD ARE 8 J PHONE <br /> .i�� �/ <br /> CONTRACTOR ADORES. I UC q{ON.�,.(�*Zi <br /> i SUB CONTRALTO ADORES ,J ! <br /> RiOHE <br /> TYPEOF WELVPUMP: XNEWWEUL ❑ REPLACEMENT WELL AMONITORING WELL! 'ZI ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL It J <br /> ❑N.13 Flopal, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ~Afir C <br /> (TYPE OF PUMP) 1EL <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I K SOIL BORINGL}' (1 -f <br /> ❑DESTRUCTION: <br /> INTENDED USE rTYPE OF WELL CONSTRUCTION SPECIFICATIONS q.� A <br /> 11I��+ <br /> INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION /'�1'/ DIA.OF CONDUCTOR CASING O <br /> 11DOMESTIC/PRIVATE GRAVEL PACK/SRE;� TYPE OF CASING/STEEI/PVC Peel DIA.OFWELLCASING i1 p <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 7r r A411 -I SPECIFICATION <br /> R <br /> ❑ IRRIGATION/AG ❑OTHER GROW SEAL INSTALLED BY - 'itl 1 64 rYA1, GRDUT BRAND NAME L _ E <br /> MONITORING GROUT SEAL PUMPED: �Va No I CONCRETE PEDESTAL BV DRILLER:❑Ya nNo S <br /> (C APPROX.DEPTH )1n'.�'- LOCKING CHESTER BOX/STOVE PIPE_ S <br /> PROPOSED CONSTRUCTION/OIIWNG METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANL <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'.SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR Wl11CR <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIEI <br /> THE FOLLOWING: '1 CERTIFY THAT_IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OI <br /> CALIFORNIAA..'' THE APPLICA T M CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED PECAIONB AT 130114") 20QCOMR E DRAWING AT LOWER AREA PROVIDED. <br /> 91prod r,{�L�( Titl OXY//NTY�EC_�/(��ILLT/lr//l/ <br /> Data <br /> L <br /> fen, <br /> PLor PLAN (Dr.to Spall Si'm <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING 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 F'ROMSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, pp ON THE PROPERTY OR ADJOINING PROPERTY. <br /> w <br /> ` Q <br /> lb , <br /> at <br /> II <br /> C M ty1 � <br /> A\/!r <br /> p <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L J�t <br /> Data Ara <br /> Grunt I,apactlon By Date Pomp Impmticn BY Dna <br /> Daatntetlpn Irepootlen By <br /> Data <br /> CernmenU: <br /> ACCOUNTING ONLY: AID! FAC! <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK!/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> S-4 <br />