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APPLICATION FOR WELLIPUMP PERM'' <br /> �r SAN JOAQUIN COUNTY PUBLIC HEALTH StR..iCES <br /> ENVIRONMENTAL HEALTH DIVISION AMCENVED <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 9MI-888MNy, 0 2 1.9:96 <br /> (209) 468.3420 SAN JL),',)UIN MINTY <br /> 17017-REFUNDABLE PERp,1,T EXPIRES 1 YEAR FROe� GATE ISSUED PUBLIC HEALTH SE•'RVICES <br /> 0111pbt$iR Triplicate) ENVIRONMENTAL Hi:ALI•{ DIVISION <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLES.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN# ���d" rih�S,_"Y. _ 1 �n <br /> ��•J CITY Trs�c 537 4 PARCEL SIZE/APNIZ,a• ( L� <br /> OWNER'S NAME_ ADDRESS /� <br /> � �i� fil/(.dsXy1( KJ _PHONE1�3z�.� <br /> CONTRACTOR Ut4s3f <br /> ADDRESS <br /> SUB CONTRACTOR SO( / �(�J1�•(,/ SONE#�? <br /> VeSADDRESS 3^ y� -/ CN ss$.2 69(a PHTke ONE — <br /> TYPE OF WELUPUMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# <br /> 11 INSTALLATION ❑ WELL SYSTEM REPAIR 13 OTHER <br /> ❑ CROSS-CONNECT REPAIR 11 VAPOR EXTRACTION WELL# <br /> 13 New❑Repelt H.P. ✓ <br /> RYPE OF PUMP) DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑ <br /> 13 DESTRUCTION: OUT-OF-SER #VICE WELL ❑ GEOPHYSICAL WELL 0 <br /> Ll 8011 BORING B <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONa <br /> ❑ INDUSTRIAL ❑OPEN BOTTOMI A <br /> 11 DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE <br /> DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO <br /> D <br /> 11 TYPE OF CASING/STEEL/PVC PUBLIC/MUNICIPAL ❑DRIVEN DIA.OF WELL CASING U <br /> DEPTH OF GROUT SEAL SPECIFICATION <br /> 13IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY - R <br /> 13 MONITORING GROUT BRAND NAME C��. IC _/U. E <br /> GROUT SEAL PUMPED: ❑Yee No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONBTRUCTION/DRILLING METHOD: MUD ROTARY �� S <br /> AIR ROTARY AUGER � C/►gLE OTHER <br /> I HEREBY CERTIFY THAT 1 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:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF <br /> CALIFORNIA.'I T,HFr AP LICANT <br /> A MUCALL 24 HOURS <br /> kvq� �g1N ADVANCE FOR ALL REQIRED 1NOPECTMNO AT 120014005423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed <br /> Title2^ <br /> L—St— Date <br /> PLOT PLAN(Drew to Scale)Scale "to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAGE 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 WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> to <br /> J <br /> DEPARTMENT USE ONLY <br /> Application Aoeepted BY Y ii' _ __ Date -o.(Q Area <br /> Grout Inspection By \ Date Pump Inspection By Date <br /> — <br /> Destruction Inspection By Date <br /> Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITISVIVICE REQUEST NUMBER INVOICE <br />