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..� APPLICATION FOR WELLIPUMP PERMIT,. <br /> n SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 98201388 <br /> (209) 488.3420 <br /> NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPMATION IB HERE BY MADE TO THE SAN JOAMIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE N COMPLIANCE WITH SAN <br /> JOADUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116„.3 AND THE STANDARDS <br /> �OF�=CITY <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, VIIWNMENTAL HEALTH OIVIBKIN. py <br /> JOB ADIDER'S NAME <br /> MN# + 4 y �p ./� �/���1�J_L'_`C�/�PAIIC�,EL//gI[FJAPN# ' A� <br /> OWNER'S NAME ��/Y/ 6ADDRESS <br /> � F V J�/RIONEE <br /> CONTRACTOR [1/%'-,� I h- T/;0 YY ADDRESS l / Y I /Y/ LICI / NE <br /> �\ <br /> SUB CONTRACTOR ADDRESS LIC# PHONE# <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> I❑ INSTALLATION 11 WELL YSTEM REPAIR 1:1 CROSS-CONNECT REPAIR 11 VAPOR EXTRACTION WELL I J <br /> Ey NI 13Sroi, H.P. y DEPTH PUMP SET—FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL! ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> E❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> uy DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEL/PVC DIA.OF WELL CASING O <br /> ❑ WBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A <br /> ❑ <br /> IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PIMPED: ❑Yr ❑N. CONCRETE PEOESTM SY DRILLER:❑Y.B ❑N. S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S <br /> RHOPoSED CONSTRUCTMONIDIOWNG METHOM MUD ROTAW AIR ROTARY AUGER CABLE OTHER <br /> 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAMIN 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 COMPDISAON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THEFOUL�IWI <br /> THAT <br /> eglwE XNG •Il �y� r N THE OMR <br /> ISSUED, EMPLOY PERSONS <br /> �SA/O}M-aU�1W�8 0F <br /> CAUFORA�pTMUSTMPUrB IN tJANCE OR REQUIRED IMCTIONS AT(2t00)4SS11PFTDRAWING AT LOWER AREA PROVIDED. <br /> PDT MAN ID,SY.t.SWeI BW. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. {. LOCATION OF MOUSE SEWAGE DISPOSALUSPOSM.SYM SYSTEM OR PMIOPoSED <br /> 3. OUTLINE OF TME PROPERTY,DIVING DIMENSIONS MD NORTH DIRECTION. EXPANBO N OF SEWAGE I'HINRDI SOF ON <br /> 3. DIMENSIONESTRUCTURES, <br /> NCL U IN AND LOCATION OF ALL EXISTING PATIO AND VEWAY , S. LOCATION OF WELLS WITHIN RADIUS PE ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCWDING COVERED AREAS SUCH AS PATIOS,DRIVFNAY6,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> T� <br /> 6� <br /> 1 ' <br /> DEC 3 ii '199d <br /> IL <br /> — - - FNTUSE ONLY <br /> Appuunnn APe -BY /—,;D So / J ` �� f^A— <br /> G-. Impectl.n BY DSS Pmp NviIPNR n By <br /> D-nmti.n Irnpctmn BY D.,. <br /> C., m <br /> ACCOUNDNOONLY: AID# FACT <br /> M CODES FEE INFO AMOUNT REMITTED CHECW/ H RECEIVED BY DATE PERRIMSFIMCE REQUEST NUMBER INVOICE <br />