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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br /> (209) 4883420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOOB INSTALL THE WORE DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> IOACUIN PDr:NteV DEVELOPMENT 1O�PIM�EN IT�TITLE,CHAWER 9--1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB .VI(A�fil/(/'11.YCfwrt� IQ// CITY �1Mg�FFf��LMV/��-/(� ��� /� fP�ARCELLBIZEIAMI�c]����Q,/(J�GlJ�A M �! <br /> OWNED:.NAME(/.VELA ` LL 1// l l7 ADDRESS ?4E/9 7160L//�Kg1�il /'/ACL 'NOL V—k,6e0 VR/W 71yi <br /> Y <br /> CONTRACTOR �/�.1.1L T/G AOOMSSS1%J S lelL&w. -742/.� PHONE Ijjd� 7y,�� <br /> SUB CONTRACTOfl .rf1 ADDRESS UC* PHONE F <br /> TYPE OF WELUPUMP: lel NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER \\ <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I �Y/ J <br /> ❑N-11M 1, N.P. DEPTH PUMP BET_". FIRST WATER LEVEL �+L'J1'/ O <br /> DYPE OF PUMP) <br /> 13 OUT-0E-SERVICE ELL <br /> SERVICE W ❑ QEOPHYSICALWELLI ElSOIL BORING B <br /> ❑DESTRUCTION: <br /> wINTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -/ A <br /> ,IeA INDUSTRIAL ❑OPEN BOTTOM /J DIA.OFWELLEXCAVATION 12 /AIC& OIA.OFCONOUCTORCASING D <br /> ❑ DOMESTKpAD .. <br /> VATE '0GRAWI-PACKMIZE_jjX/`_ TYI£OFCASINGISTEELMCCy�1(II( DIA.OF WELL CASING � 4�� O <br /> ❑ MBUCIMUMCIPAL El DRIVEN DEPTH OF GROUT SEAL IU?I-'r SPECIFICATION SC*.1/10 A <br /> ❑ IRNGATIONIAG ❑OTIIER GROUT SEAL INSTALLED BY40%__G(IN%M GROUT BRAND NAME �. �_y� F <br /> ❑ MONITORING GROUT SEAL PUMPED:13Yy ❑N. CONCRETE PEDESTAL BY DRILPB:❑Yr Y5M4 S I�— <br /> APR10x.DEPTH A/0 LOCKING CHESTER ROXISTOVE RPE S V <br /> PROPOSED CONSTRUCTIOH/ORLUNG METHOD: MUD ROTARY AIR ROTAJW—AUGER CABLE OTHER O <br /> Q <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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 CENT"THAT IN THE PERFORMANCE OF THE WOR(FOR NMICH TT-I <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES 1 l <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATON LAWS OF <br /> CAUFOIPIIAITIE C T MUST C LL U HOUIRS IN ADVANCE FOR ALL REQUIRED INS P �ORB <br /> AT <br /> cal 448411e23. COMPLETE DRAWING AT LOWER AREA P O IDEED. <br /> Sig ne x�r TIGe !/G!iTI.N�I A/J/ 0., 2✓ <br /> PLOT PLAN IDr.W Me SW.1 Style 'b 9 <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUrUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. \� <br /> 3. DIMENSIONED OUTUNES 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 WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> J <br /> MA m c1ts A <br /> twoi <br /> 4 <br /> suoP <br /> rEAiyE <br /> synsm <br /> W- -E <br /> S r - . <br /> DEPARTMENT USE ONLY <br /> APellwllen AP. i By <br /> CroN lypeoll.n Bya2 Da- Mu P Impeallen fly D.I. <br /> Oytrwlbn Iry.ellon BY Uete <br /> LammNlb: <br /> 3 f � <br /> ACCOUNTING ONLY: AID# FACJ <br /> PE CODES FEE IN(FIO AMOUNT REMITTED C"EC RECOVED BY DATE P6N11TISERVICE REQUEST NUMBER INVOICE <br /> V <br />