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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O,BOX 388,904 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)469.3420 <br /> 110111•REFUNDARLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICemplltl in Triprnme) <br /> APPLICATION IS HERE BY MADE TO T/IE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW 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 <br /> HEAL�THH�SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AOORESS/Oq ADQN1_ Q `S E//D6•r'n C/o CIT" <br /> J/��l /✓� PARCEL SIZE/APN&ZZt –A950–Q� <br /> OWNER'1 NAME._Q,(/Z/''H' JZr O J1YJG Y� ADDRESS. /"� l � /f��P.H�OyN'E I /y�" <br /> CONTRACTOR '`�� JF�/O�/73 PHONE�O7� y:sC2/�5 <br /> !1OBzeNFR?ACTu+ l 04fe rd M ADDRESS C/ p10NE I� <br /> T <br /> TYPE OF WELLIPUMP: ❑NEW WELL ❑RER.ACEMEHT WELL ❑MONITORING WELL* ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL/ <br /> TYPE OF PUMP) ❑N—El P—.ir H.P. DEPTH PUMP GET FT. FIRST WATER LEVEL O <br /> ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL/ 601E BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONITRUCTION SPECIFICATIONS�y A, A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION (J DIA.OF CONDUCTOR CASINO '�� D <br /> ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELIPVC "�J� OLA.OF WELL CASING D <br /> ❑P UBLICIMUNICIPAL ❑DRIVEN )) ` DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑IRRIGATIONIAO OTHER AC/`/1T!y e.sj x GROUT SEAL INSTALLED B {�i r GROUT BRAND NAME E <br /> ❑MOMTORINO 'YY GROUT SEAL PUMPED:,ftY« [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑W S <br /> APPROX.TERN LOCKING CHESTER BO%TTOVE PIPE S <br /> MLOPOLED CONSTRUCTION/OIIBLUNG METHOD: MVD ROTARY AIR ROTARY AUGER OK CABLE OTHER <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COVNrY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IB ISSUED,1 914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENIATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFNSATWN LAWS OF <br /> C.LIFORNIA.' T//E IMJCAI T MU� MS INA NCE F00 ALL REGUInE 11N/1�PFC"ON/AT 1)201 11!3422,COMPLETE DRAWING AT LOWER AREA PROVIDED <br /> D.I. Z22 <br /> KOT M-AN IDr—IP 81N.1 SP.I. 4 tP <br /> 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> ! OUTLINE OF THE PIOPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> f,DNJENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTVMS,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> v <br /> e <br /> oB"7 <br /> -!51B�. <br /> � s�r�1 U c off. <br /> GrGi <br /> • �`��f', . () DEPARTMENT USE ONLY <br /> APPFealen Aeo.ptd BY b.b Ary <br /> Grout Impeellen 0Y D.t. P—,IrnP.Ptlen By D.t. <br /> Datnctbn 1rrP.end,BY D.h <br /> C--...: <br /> ACCOUNTING ONLY: AID! FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHE K /CASH RECEIVED■Y DATE PERNIIi/1ERICE REQUEST NUVMM INVOICE <br /> Pub.Health Serv.-Envlro.173(3196) <br />