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APPLICATION FOR WELLIPUMP PERMI <br /> - _AN JOAQUIN COUNTY PUBLIC HEALTH SERv.,, <br /> ENVIRONMENTAL HEALTH DIVISION cop <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201388 � <br /> (209( 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> lCoAPPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT I CTAN r I <br /> OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPT 19-1116.3 Alp THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH MVISKIN. <br /> JOB ADDRESSOR APN# l! :JY` S n I Q L �1 <br /> /n�11 LL ! CITY I,/ CP/ALRCEL BIZE/APNI �L l S-2 <br /> .'1 <br /> OWNER'S NAME 1 •/_11 N /+ 'lRr ADDRESS n� X 141 IV Jy-L+C�7 PHONE B J I o` <br /> CONTMCTOR C •1 ADDRESS 2 0 Z y F�, C A i�j� LICI 37 5 Lf PHONE <br /> SUB CONTRACTOR ADDRESS <br /> LIC# PHONEi <br /> TYPE OF WELURMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL i <br /> El New❑RepAl. H.P. <br /> RYP OF RMPI DEPTH PUMP SET FT. FIRST WATER LEVEL p <br /> 4 .0­0 <br /> 1 <br /> ❑ OUT OF-SERVICE WELL ❑ GEO SICAL WELL R El SOIL BORING <br /> 1 B <br /> ❑DESTRUCTION: Air (6 4 . 01 u/ � f A e W74 _ <br /> INTENDED UHE TYPE OF WELL CONSTRUE TION SEC CATIONS <br /> El <br /> A <br /> INDUSTRIAL C1OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> 11DOMESTIC/RSVATE 11 GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING p <br /> D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION B <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT BEA&PUMPED: ❑Ys [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ON. 5 <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S <br /> PROPOSED CONSTRUCTIONIDRIWNO METNOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORE WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(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: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA." THE APPLICANT MUST CALL N HOME IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(IMI 4018J 22. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 6l'r Xe <br /> Title DKP <br /> rl <br /> KOT PLAN(D,.to SA&I.)Smola "to uv.� <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDIN THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED \' <br /> I. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DfSPOSAL SYSTEMS. (r'I <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAU(S. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> I� <br /> —FA l t �tilc. II <br /> 1L pip` <br /> PAvMEN-r <br /> Fd C:EIVE'O <br /> MAR ?—Hlglq n ,/ -- <br /> SAN JOAquINCOUNry c 1 <br /> Pl lLiLIG f-IL I I li T.f.!Rt ISI S <br /> ENVIRONMENhu N;A!.1H UTAII dt�r� <br /> DEPMTMMT USE ONLY <br /> Appfi Ptb AeoepRed BY Pla 7/I A,- <br /> Groh Itnpstlon BY Dete Pump Impeetlon BY Ox#� <br /> DmitmtIon ImpoetPo BY DAtA <br /> CP P`.'.: <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT RVkTTED HEC /CASH I RECEIVED BY I DATE PEIIMITIHEIRVICE REQUEST N11MBEI1 INVOICE <br /> '- <br />