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APPLICATION FOR WELLIPUMP PERMIT - <br /> 4/SAN JOAQUIN COUNTY PUBLIC HEALTH SERBS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O, BOX 388,304 EAST WEBER AVENUE, STOCKTON. CA vM1.988 <br /> (2091460-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplintel <br /> APPLICATION is HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORT(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-11 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APN# ZMZZ U 1'-6CRY L PARCEL SIZFIAPN; - — O Q <br /> OWNER'S NAME_ ADDRESS ,>d r G PHONE# <br /> CONTRACTOR v _ ` ll3S'a nrr►r i (cert. <br /> ADDRESS In C Lia. tic; 747, (g PHONE; /d <br /> i <br /> SUR coNTlsatcrDR ADIx1Esa LIC# PHONE# <br /> TYPE OF WELIJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> 13 N.1:1 Repair H.P. DEPTH PUMP SET FT. <br /> (TYPE OF PUMP) FIRST WATER LEVEL O <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ed SOIL BORING g <br /> ❑DESTRUCTION: <br /> F: <br /> t <br /> INTENDED USE TYPE OF W CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN TTOM DIA.OF WELL EXCAVATION Z 'el DIA.OF CONDUCTOR CASINO_-g/+��/'T __ p <br /> t ❑ DOMESTIC/PRIVATE ❑G L PACKIs[ZE TYPE OF CASING/STEEUPVC_. 444 . DIA.OF WELL CASINO <br /> ❑ PUBLIC/MUNICIPAL ❑D VEN DEPTH OF GROUT SEAL ("Z C r SPECIFICATION R <br /> ❑ IRRIGAr10NlAO OTHER GROUT SEAL INSTALLED BY CL+.t a&t , GROUT BRAND NAME e <br /> MONITORING j GROUT SEAL PUMPED: ®Yea ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yee tJtl Ne S <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE $ <br /> PROPOSED CONSTRUCTIONMRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER�� <br /> I HE13EBY 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 JOAOUfN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I 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: 'I CERTI THAT IN THE PE RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T K =MUST HOURS IN ADVANCE FOR ALL REQUIRED 1/SSPtCC�TIONa AT 1204)488.3428, COMPLETE DRAWING AT LOWER AI* OVID O. O <br /> Slpned X Title �r �7W <br /> PLOT PLAN[Draw to SaMsl Scala "to <br /> 1. NAMES ST ETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE HE 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 /> SC : . <br /> Proposed Soil Probe.Locatio {�.E <br /> Powat'.tpola <br /> 0 0. <br /> EXCSVB Wla <br /> StoregQ arch O <br /> at <br /> I <br /> QFFICEB Q CSI ,-E <br /> (PUMPS REMOVED) <br /> DEP USE <br /> DEPARTMENT U ONLY <br /> Applloatlon Accepted By Date LArea <br /> Grout Irnpectlon Sy Date Pump Impectfon By Date <br /> Destruction Impaction By Date <br /> Comments <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC RECEIVED BY A-7 <br /> POWITISERVICE REQUEST NUMBER INVOICE <br /> � <br />