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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICtS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA SIM 388 <br /> 1209► 468.3420 <br /> NUN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete IN Trlplicalal <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT <br /> �SUB CONTRAJ DEVELOPMENT T1ITLE, CHAPTER <br /> 9-1115.3.3 AND THE STANDARDS OF SAN <br /> JOAQ <br /> UIN <br /> UNTYUBLIIC,HIEVALT(H/r�SLE.QR,2VIi�CL ED, ENVIRONMENTAL HEALTH DIVISIO <br /> N. <br /> JOB ADDRESSIOR APPH# ( ZDI 511 Q�LL� S4CITYPARCEL SIZE/AM# <br /> OWNERG NAME ; o , k %Rr _ ictic' hJ ADDRESS ntr. PHONER 3 (.e <br /> o � G, <br /> TOR tIkMONE P <br /> C <br /> TYPE OF WELL/PUMP: ❑ NFW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL a <br /> ❑ How ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL V <br /> (TYPE OF PUMPI IIJ� � 1� <br /> 11T-OP oUSERVICE WELL ElGEOPHYSICALZ <br /> GEOPHYSICAL WELL S SOIL BORING <br /> ,A Yej A44) l, a <br /> El DESTRUCTION: <br /> I� J CPy/ <br /> IN T ENOEO USE TYPE OF WELL CONSTRUC1109 6PECIHCATIONB /,'T A <br /> 11 INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELLEXCAVATION 10 . VIA. OF CONDUCTOR CASINO D <br /> ❑ DOMESTICIPRIVATE 11 GRAVEL PACK/SIZE TYPE OF CASINGISTEEUPVC -- DIA. OF WELL CASING D <br /> ❑ PUBUC/MUNICIPAL ❑ DRIVEN DEPTH OF 090" SEAL FICATI N _ a <br /> ❑ IRRIGATIONIAG ❑ OTHER GROUT SEAL INSTALLED BY VIr RANNTA�MEQ`�V•� E <br /> ❑ MONITORING /7 GROUT SEAL PUMFEM ❑ Yr ❑ No CONCRETE PEDESTAL BY DRILLER: ❑ Ys [IN. 5 <br /> APPROX. DEPTH `/j LOCKING CHESTED BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONIUISLUNG METHOD: MUD ROTARY AIR ROTARY AUGER. CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULED ANO <br /> REGULATIO 9 OF THE RAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIED THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> TRIG MIT IBI UED, 1 SHALL <br /> NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HINNG OR BUD CONTRACTING SIGNATURE CERTIFIES <br /> THE LLOWING: 1 CERTITY THAT IN THE PERFO MANCE OF THE WORT( FOR WHICH THIS PERMIT IG ISGUED, I SHALL EMPLOY PLn60NS SUBJECT TO WOMKMAN'e COMPENSATION LAWS OF <br /> CANTO IA.' THE PeIICANT MU T C 21 E RS A VANCE FOR ALL REQUIRED INSPECT1ON//11�,AA�T I30e14ae313]. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blpmd X TIIIa �AA/ /(�/�i!(y[GY�iJ Date 2 " <br /> PLOT PLAN IDrew to Gealel Dvalo <br /> 1 . NAMES OF STREETS OR ROADS NEA TO OR BOUNDING THE PROPERTY. /. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> p, OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH OmFCTION. EXPANSION OF SEWAGE DISPOSAL eYSTEM6, <br /> 3. DIMENSIONED OUTUNE6 AND LOCATION OF ALL EXISTING AND PROPOSED G. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOe, DRIVEWAYS, AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> Ir <br /> O TMENT USE ONLY <br /> I /J <br /> i AppllvnUen Aveeplal BY Date [..- Area <br /> i GrowImpeallen By. Oeta Pump Iropmtloo BY U� <br /> a <br /> Devctlen Invpovtlo, BY Date <br /> cemmae.:_�_ <br /> ACCOUNTING ONLY: AID,( FAC/ <br /> PE CODES FEE INTO AMOUNT REMITTED CHEC /CASA RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> o?eh 013 4 A <br /> D v <br /> iso l <br /> Pub. Health Sew. - Enviro. 173 (3/96) <br /> i <br /> k <br />