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i <br /> '?PLICATION FOR WELLIPUMP PERMIT 1. <br /> SAN:,. ,AQUIN COUNTY PUBLIC HEALTH SER�.,;;ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ' 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> l <br /> NOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> I <br /> A (Complete fro TrillkntelAPPLICATION IS HERE BY MAGE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WHl1 SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDAj�Rne OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APNI &IA' L l <br /> CITY PARCEL SIZE/APNN <br /> OWNER'S NAME � �4\r,,� <br /> ADbRE88 ln .PFIDNEx "iCONTRACTOR me' -�J I�''Atic, LPA PHONE <br /> SUD'e6W ADDRESS <br /> LICI PHONE 1 <br /> TYPE OF WELQ MP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATKIN ❑ WEL STEM REPAIR ❑ CROSS-CONNECT R PAIR ❑ VAPOR EXTRACTIO LL/ <br /> 4 1 J <br /> I ❑NewRepelr H.P. DEPTH PUMP set CT <br /> FIRST WATER LEVEL <br /> IrYPE OF PUMPI 'y d <br /> 1fl ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL*— ❑ BOIL BORING $ <br /> ION: .y <br /> C 1-1) I <br /> INTENDED USE TYPE OF WELL ONBTRUC710N SPECtFICATIONB <br /> D INDUSTRIAL ❑OPEN BOTTOM A •-� <br /> I DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> I�DOMESTICA"VATE OGRAVELPACKISIZE D <br /> TYPE OF ChBINGlST EERJPVC DIA.OF WELL CASING <br /> ❑ Pl18LIClMUNICIPAL ❑DRIVEN b <br /> DEPTH OF GROUT SEAT. SPECIFICATION R 1, <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAR INSTALLED BY <br /> GROUT BRAND NAME `'T1 <br /> F <br /> F R O.DEPTH <br /> GROUT SEAL PUMPED. ❑Yea [Iwo <br /> CONCRETE PEDESTAL BV bRIILER:❑Yne ❑No <br /> + <br /> APPROX.tlL'PTH LOCKING CHESTER BOXlBTOVE PIPE <br /> PROPOSED CONBTRUCTIO"MAILUNO METHOD; MUD ROTARY AM ROTARY <br /> AUGER CABLE OTHER S, <br /> I <br /> ^tib\`i <br /> I I EGUEAY CERONS FY THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> y <br /> REGULATIONS OF THE SAN JOAQUIN NOT <br /> COUMy, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERrIFfES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF T11E WORK FOR WIBCII <br /> 11r[ THIS PERMIT IS ISSUED,t SIfALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR 8U6-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWI '1 CERTIFY THAT IN THE PER �IIgqqMMM���,t�ANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PER SUBJECT TO WORKMAN'S CpMF•ENBATlON LAWS OF <br /> CAUFORN! T• 'AI- <br /> A T MUST CALL 2 41118 IN ADVANCE FOR ALL REOURRE'D 1 TIONS AT 12 $4603.22. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> �f <br /> 81iJned X l...r• <br /> Tltla <br /> J r`r` Data r- �• <br /> I6 'ti.• <br />` PLOT MAN Ibra to 8ealel 8tiale •to <br /> I. NAMES O ST EET8 OR ROADS NEAREST TO OR BOUNDING THE PROFERT'y. - <br /> 2. OUTLINE O THE PROPERTY,GIVING DIMFH8IONS AND NORTH DIRECTION. CATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 7. DIMENSIONED OUTLfNF.B AND LOCATION OF ALL EXISTING AND PROPOSED - 1RPA TIONSION F SEWAGE rMNDISPOSALD SOF ON, <br /> B. LOCATION OF WELLS WITHIN fV1OlU8 OF ONE HUNDRED FIFTY FT. <br /> 67RUC7URE8,INCLUDING COVERED AREAE SUCH A8 PATIOS,DRIVEWAYS,AND WALKS. m THE (�- <br /> OR ADJOININO 4'ERTY. <br /> f <br /> ' � � <br /> r PAYS <br /> .. PEC <br /> it 1991 <br /> �iaif JHEAQ 5IJ <br /> ,,. FA1VrfQN1SREfVFAl-Ht A <br /> .......: . ..... . <br /> i 7Pr !V Slnf <br /> -'.. <br /> DEPARTM$NT UAE ON4Y' _ <br /> APPfleat%n Aeeeated By l <br /> d Re Arm <br /> Grout tmveerian By �� Date <br /> ` Mn0 lmaaotten 8y Date •,�~ J <br /> D—Irt:tion Impectien By �T <br /> II Date <br /> Comments: <br /> M. <br /> ACCOUNTING ONLY: i4. AItl.1 FACT <br /> PE COOEB FEE INFO !AMOUNT REMITTED EC (CASH RECEIVED By DATE PERMITISERVICE R£GUEST NUMBER INVOICE <br /> QP-71 ko0 I 4 D�p5 <br /> I� <br /> I � <br /> Pub.Health Serv.-EnViro.173(1/97) <br />