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-move \111111111111f <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERI.-ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I_YEAR FROM DATE ISSUED <br /> (Complete in Tripliest9) <br /> APPLICATION 19 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 TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNN (C'.L, L�- Ls' (r�� _,�1 L/ e CITV ./ PARCEL SIZE/APNA' <br /> OWNER'S NAME rt� -ri { , ✓ `I UPHo�NE,► ! <br /> (f <br /> ADDRESS �_ 3Z <br /> CONTRACTOR J/ V e— 04y -,1-� ! /!— o.L ADDRESS_1 a ,sY.'t/a�ov; UCI! :S' 17 PHONE G 03 <br /> � <br /> SUB CONTRACTOR_LT'p`.?lJt./ l)/i l(rt..n - '�l�..J G. ADDRESS�.I�� ffi'ur_.�(+'GS.,i�1r�Y°!-rel�,-IJC+T `tfr/(I j PHONE#,(f-/j <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> ❑New❑Repalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0. <br /> (TYPE OF PUMP) <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL X SOIL BORING <br /> J <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION VIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING (— •, GROUT SEAL PUMPED: ❑Yes [IN. CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S <br /> APPROX.DEPTH 1 ,..c'. LOCKING CHESTER BOX/STOVE PIPE g <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER% rrd e �' P'S4 <br /> I HEREBY CERTIFY THAT I 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLO NG: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNI HE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION&AT 112091409-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed x �V .v�L t-- Tkle .C C Y?G i sL ,� c �t"`�%l_I Date <br /> I / <br /> PLOT PIAN(Draw to Scale)Seals <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 PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> �I r.-rnncc OJct UnING COVERED AREAS SUCH AS PATIOS DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> L '.., <br /> DEPARTMENT USE ONLY <br /> Application Accepted BY f (.- ' <br /> Date__Lt'r Area <br /> GroLd Impaction By j a t <br /> �c Date;a' pCmp inspection By <br /> Destruction Inspection By <br /> Date <br /> Date <br /> Comments: <br /> l <br /> ACCOUNTING ONLY: AIDN <br /> FACT <br /> PE CODER FEE INFO � <br /> AMOUNT REMITTED CHECK ilCASH REC ElVED BY DATE <br /> P$iMiT/r&ERVICE REQUEST NUMBER INVOICE <br />