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APPLICATION FOR WELLIPUMP PERMIT <br /> AN JOAOU' LINTY PUBLIC HEALTH SERVIL <br /> ENVIR'WENTAL HEALTH DIVISION <br /> P 0 BOJ(388,445 N.SAN JOAQUIN ST., STOCKTON,CA 95201.368 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Compl•t•in Triplicat•) <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 TITLE,CHAPTER 9-1115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESSroR APII FSS" (' Q(M'�(,y , CITY7-1 <br /> l G' <br /> PARCEL SIZFUAPN/ <br /> OWNER'S NAME / ,7 ADDRESS A , r 7 C/✓� <br /> PHONE/ <br /> CONTRACTOR C fe R 6tJ C!' /tryp GR ADDRESS <br /> he— rCi PHONE I O � 7 [7 <br /> SUBCONTRACTOR I ( i 'N V" ADORESspol c 0 Lic/G'7.Z/s/7PHONE•`j/l/YS?9ybr <br /> ' <br /> TY75-' � <br /> PE OF WELLIPUMP, El WELL 11 REPLACEMENT WELL MONITORING WELL/IZW�1 ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL/ <br /> ❑New U 'R <br /> LTs.lr H.P. T FT. <br /> RYPE OF PUMP DEPTH PUMP SE � FIRST WATER LEVEL O <br /> ❑ <br /> DESTRUCTION: 11OUT-Or-SERVICEWELL ❑GEOPHYSICAL WELL I ❑ SOIL BORING <br /> B <br /> INTENDED VSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑INDUSTLBAL ❑OPEN BOTTOM / 1 A_ A <br /> DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 'y/� D <br /> ❑DOME571ClPRIVATE ❑GRAVEL PACKlSgE .Q U� TYPE OF CASING/STEEVPVC V DIA.OF WELL CASINO_ 'r <br /> D <br /> P18L1C/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SIAL SPECIFICATION <br /> ❑IRRIGATtON1AG ❑OTHER GROUT SEAL INSTALLED BY P'1 I GROUT BRAND NAME B <br /> F <br /> MONITORING r, GROUT SEAL PUMPED:❑Yw �Na CONCRETE PEDESTAL BY DRILLLR;o ❑Ne S <br /> APPROX.DEPTH 3y LOCKING CHEULMWXISTOVE P _„PE _ <br /> PROPOSED CO N•TRucTIONIDRILLNO METHOD: MUD ROTARY AIR ROTARv S <br /> AUGER_CABLE OTHER <br /> 1 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 FOLLOWING: "I 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 /> CAUFURNIA,' T E APPLICANT MUST CALL2S N Wf IN ADVANCE FOR ALL REQUIRED I • CTION•AT 120.1 ICOMPLETEa33.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signal X 1 r <br /> Title <br /> PLOT LAN fD,—I.S..i.l S-1. l` •tP�_ <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. SAL SYSTEM OR PROPOSED <br /> HOUSE SEWAGE DISPOSAL 4. LOCATION OF <br /> 2,OU TUNE OF THE PROPERTY,GIVING DIMENSLON6 AND NORTH DIRECTION. EXPANSION F SEWAGE DISPOSAL POSTEM8. <br /> J.DIMENSIONED OVTLINFS AND LOCATION OF AL1 EXISTING AND PROPOSED 64 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 /> 1 - ' - <br /> bA Lk" <br /> DEPARTMENT USE ONLY <br /> APPIle.tlen A—,ted By <br /> Date Ars <br /> Grout Impmticn By D.te <br /> R•++P ImP«11Pn By ons <br /> Datr.etlen I-I—tion By D.1. <br /> cemmR,:.: <br /> ACCOUNTING ONLY: Al.. FAG/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK/ICASH RECEIVED By DATE PERRAITmERVICE REQUEST NUMBER INVOICE <br />