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APPLICATIPH FOR,%VEL[HTUMP PERMIT <br /> SAH JOAQUIN COUFJTY PUBLIC HEALTH SERVICiV <br /> EHVIROHMERTAL HEALTH DIVISIOFd ! <br /> P.O. BOX aft 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 0o t tl <br /> AL <br /> (209) 460.3420 <br /> 1100-fluunnADIE prnmT EXPIRES 1 TEAR FROEI DATE ISSUED <br /> (ComPhto <br /> In Tr�pftotoj <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCTAND/on INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1 116 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIV1810N. <br /> JOB ADDRESSOR APN# 0 <br /> V <br /> OWNER'S NAME ctrl, PARCEL SIZE/APN# <br /> �,., r // "qf- <br /> ADDRESSIPF10NE#CONTRACTOR F I Flo trG vtI qQ/ AODRESB IJC# " PHONE "3 I• ,L� <br /> RUB CONTRACTOR t` Q V� _ X ADDRESS &ttIN B t C 1 -+��_ <br /> ' LICA-I�71Vf- P14ONE <br /> TYPE OF WELL/PUMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL IF ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> (TYPE OF PUMP) ❑New❑Repair H.P. DEPTH PUMP SET FT. <br /> FIRST WATER LEVEL p <br /> ❑ <br /> 11 DESTRUCTION: OUT•OF-SERVICE WELL ❑ GEOPHYSICAL WELL# 10 SOIL BORING __ <br /> B <br /> INTENDED UdE - TYPE OF WELL - - - CONSTRUCTION SPECIFICATIONS IA1 t I <br /> T'V W A <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO <br /> D <br /> DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO p <br /> ❑ PUBLIC/MUNIC$'AL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION q <br /> ❑ IRRITATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ ONITOIV GROUT SEAL PUMPED: ❑Yee ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y« ❑Ne S <br /> APPRR OX.DEPTHH Q s O T" LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER,_ <br /> 1 HMRY CERTIFY THAT 114AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PER►ORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 814ALL NOT EMPLOY PERSON$SUBJECT TO WORKMAN'0 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORX FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSON8 SUBJECT TO WORKMAN-0 COMPENSATION LAWS OF <br /> CAUFORNIA.' HE AIFT MUC ALL 24 HDIR40 IN ADVANCE FOR ALL REGU:RED INGPECT12 0 AT 12001 4422. COMPLETE DARWIN AT LOWER fIWA PRO ED. �1f� <br /> Stoned Title ebwplIZt <br /> ata '�S T <br /> PLOT PLAN IDrew to$estel Soete 'to <br /> 1. NA E STREETS OR ROADS NEARS TO On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLIN OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINED AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDMD FIFTY FT <br /> OTRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> i <br /> r <br /> DEPARTMENT U8E ONLY <br /> Appstlon Accepted By Y Date ( �� <br /> lloArea Dv <br /> Omit 6xpeetlen By Date Pump Inspection By Date <br /> Destnretlon I—pecti—sv not. <br /> 5�eOl7o0 <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODE* FEE INFO AMOUNT REMITTED CHECK#ICABH RECEIVED BY DATE PERMITISENVICE REGUEBT NUMBER INVOICE <br /> Pub.HeaRh Serv.-Enviro.173(3/96) <br />