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APPLICATION FOR WELLIPUMP PERMIT <br /> ,SAN JOAOUIN COUNTY PUBLIC HEALTH SERVI6.,,/ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST. STOCKTON, CA 95201.388 <br /> (209) 468.3420 <br /> NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE COP Y <br /> (Complete In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APALICATKIN IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC <br /> PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESS/OR APN#_ 1 1, 3/'v'T tel -r,( F V I 2 O CITY (..L01 PARCEL 81ZE/AM# �J( / <br /> OWNER'S NAME_lj(((Q1,1H 'j a^ r(Z ter / / / ADDRESS SA <br /> "4z /T ,]I.Z-EHE, ,'L ! PHONE R c -Otl <br /> IV <br /> CONTRACTOR Nlol-) ti' 0 imp en ADDRE36 Y-�(ln (J F/ /t'N/VT LION JJI,�g10NE M <br /> SLAB CONTRACTOR ADDRESS STKw %', UC# PHONE Y <br /> TYPE OF WELVPUMP'. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ <br /> INSTALL <br /> -A--ILILA/�TION ❑ WELL SYSTEM REPAIR 13CROSS-CONNECTREPAIR ❑ VAPOR EXTRACTIONIlWELL Y J <br /> SR-E.�JrnP esl a!v ❑New Gl<.l. H.P. �P DEPTH PUMP SETZ6G <br /> f. FIRST WATER LEVEL Q! D <br /> nYPE OF PUMP) ! <br /> z.4"e- Q�jbr/ PU N� ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g <br /> 13 CDESTRUCTION'._ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> r <br /> ❑f INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> 13 DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELNVC DIA.OF WELL CASING D <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION g� <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E (� <br /> ❑ MONITORING GROUT SEAL PIMPED: Ely. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Ys [IN. S, <br /> APPROX.DERTN LOCKING CHESTER BOX/STOVE PPE g <br /> PROPOSED CONSTRUC IONADRILNNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPJCATION 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 R�c' <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 1 <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS KAMM D. <br /> IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF C <br /> CALIFORNIA.' THE US HOURS AO FO <br /> E R ALL REOIN III <br /> O )j MPLETE pRAWINO AT LOWE0.ANEA�PROVIDED. <br /> hl. ­q-5' <br /> PLOT RAN ID,.to S .j Goal. •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR FROPOSED <br /> 2. OUTLINE OF THE PRORRTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 5. 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 /> (3c90 T <br /> I I.LrL- <br /> ti <br /> ' ? ',` <br /> Il h <br /> DEPARTMENT USE ONLY <br /> ApPlicetion Acccptetl By �f✓n � I_�� yAra,�� <br /> Gmm 1 vp tion By Leo Pump Impaction BYE V D.te <br /> Dsvuctlon Impaction By w,. <br /> C.—.1.: <br /> ACCOUNTING ONLY: AID# I FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED A--4#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST//NNURABER INVOICE <br /> /� 1� <br /> e l%ESV JK_/ <br />