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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> � ENVIRONMENTAL HEALTH,DIVISION �O nM . <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICampleto In TFiptkanl <br /> rAPPLICATION IS HERE BY MADE TO THE'SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DMB ON, <br /> J11OB ADOFI£SSIOR APNf CITY PARCEL GJZEJAPN4 <br /> OWNER'S NAMEU I/� ,ADDRESS /C- ' F'� PHONE I.. q�-- a <br /> I 3yCONTRACTOR ADDRESS LICK PHONER <br /> r , <br /> f 6 U1 CONTRACTOR ADDRESS LIC/ PHONE# <br /> ` TYYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONIFOMNO WELL R 13 OTHER <br /> � 11INSTALLATION IJ WELL SYSTEM REPAIR --ACROSS-CONNECT REPAIR 11 VAPOR EXTRACTION WELL# <br /> ❑New❑Ropalr H.P. DEPTH PUMP BET FT. <br /> (TYPE OF PUMPI FlRBT WATER LEVEL <br /> O <br /> [� © OUT-OF-GERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONfiTRUCTION sPEWFICATIONS A <br /> I © <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑O DOMESTICMMVATQ ❑GRAVEL PACKJSIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO D <br /> D PUBLICIMUNICIPAI ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION p <br /> IRRIOATRONlAG ©OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING OROUT SEAL PUMPED; ❑Ye. ❑N <br /> 4 e CONCRETE PED£ETAL BY DRILLER:❑Ya ❑No $ <br /> A9PRO7(,DEPTH LOCKING CHESTER BOXISTOVE PIPE 6 <br /> 'I <br /> PROP03ED CONSTRUCTTONXIMMNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> Ip , <br /> I"OVAY CERTIFY THAT'HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN CgUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,1 SI4ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIJVNO OR 011B.ComTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN TT <br /> HE PERFORMANCE OF HE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEHIRATION LAWS OF <br /> C`1ALIFORMA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION&AT 1201408.3423. COMPLETE DRAWING AT LOWER AREA PROVIDED, <br /> Glpned X + <br /> Title <br /> PLOT PLAN tO,ew to Beata)Sd.le '!e <br /> t. P RTREETB OR RO 8 M AITEST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DIRPOSAI SYSTEM On PROPOSED <br /> 2.I OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. , <br /> 3.I DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED - B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNORFD FIFTY R7. <br /> !STRUCTURES,INCLUDING COVERED AREA8 SUCH All PATIOS,DRIVEWAYS,AND WALKS. ON THE PIgPERTY OR ADJOINING PROP'FFITY, <br /> f lLz.c�Sl .. <br /> Ali <br /> j� <br /> k _ <br /> rte" <br /> - ., _ JJ - <br /> J <br /> .1 .. ... ..:. - ., - <br /> ....` . Fr� <br /> "-- '- DEPARTMENT-USE ONLY. ,-,�...�. . <br /> Apoflaollon Aaaeplad By � <br /> bat• Ars.�� <br /> Dn�knOr ut Ir,apbetlen BY. OHa p ne�eellon y~ Dat. <br /> ` s <br /> etMn lmnxt <br /> 3I <br /> "ACCOUNTINO ONLY: AFD# FACS ! <br /> 1PE CODES FEE INFO AMOUNT REMITTED CHEC A$H RECEIVED BY DATE PRIIMITISERVICE REQUEST NUMBER INVOICE .PPP <br /> I 1 <br /> Pub.Health Serv.-ERviro,173(1/97) _, <br />