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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 2 • -y <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED 1032-3-0 0 r <br /> (CompMts In Trilikatel <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TrTLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSMR APN# r CITY' /�/ / PARCEL SIZE/APN# Q <br /> OWNER'S NAME .�UG� JC. ADDRESS "7'7 J��a/n PHONE I /wQj 1 <br /> CONTRACTORWJ IKA ADDRESS //yam ��L � p--�9 PHONE# e4C /--3 <br /> - Z/,a <br /> AUS CONTRACTOR 511 22!a4i/// ADDREBS�: UC# /�PHONE# ✓rZZ—f/ <br /> TYPE OF WEL.IJPUMP: NEW WELL 11 REPLACEMENT WELL ❑ MONITORING WELL# 13 OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> t/VPE O__ &-� ❑RepaM H.P.T'S DEPTH PUMP SETT. FIRST WATER LEVELPUMPI <br /> O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING S <br /> ❑DESTRUCTION- <br /> INTENDED USE TYPE'07 WELL CONSTRUCTION SPECIFICATIONS u A <br /> ❑yyy�LLI_N��_moTPoAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION__. �//Zyy//��.. DIA.OF CONDUCTOR CASINO 0 <br /> �MEBTICIPIgVATE RAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO_ [p 7 0 <br /> /❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION GL� yv R <br /> ❑ IRRIOATION/AG ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME � �}�� E <br /> ❑ MONITORING GROUT BEAL PUMPED ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yea�p ye s <br /> APPROX.DEPTH LOCKING HESTER BOXMTOVE PIPE <br /> PROPOSED CONSTRUCTION/DRIlUNO METHOD: MVD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE9ESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE M ACCORDANCE WITH BAN 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING, C IFY ATM PERFORMANCE OF THE WORK FOR WHICH THIS PERMrT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' HE MUS URS IN ADVANCE FOR ALL REOUNIED INSPEQTMNSAT t20111 40844n. COMPLETE DRAWING AT LOWER AREA PROVID O. <br /> Swwd X Title C�lr'L►Ylgz� <br /> Data <br /> PLOT PLAN(Drew to scale)Seel* 'to <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,GIVMG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED - S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS, �0 3—� ON THE PROPERTY OR ADJOINING PROPERTY, <br /> f� <br /> s'-- --------� AUG � � <br /> _11TAL HEALT1- <br /> ' .HFI <br /> t <br /> DEPARTMENT USE ONLY <br /> Application Aeeapted ey <br /> Grata Irnpeetlen By , Dats PUm Inapeetlen By 'Daly—'i"-- <br /> or <br /> Deatnratlen lmppwt#on�8 �;.�, /�/, y'') Gate <br /> Commems:_ AX_ _ t� C.. 6 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BY DATE PE MIT/SEIVICE REQUEST NUMBER INVOICE <br /> 57 o oa �— <br /> Pub Health Serv.-Enviro.173(1/97) <br />