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, <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> . ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCIiTON, CA 9620f•388 <br /> X ,�>d >`-i►cN <br /> (2091468-3420 J'UC2T)A csJ:� <br /> Lt�F1-� <br /> t <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete is Triplicate) <br /> 'PLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANI INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> IAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER S-111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> FADDRESSIOR AEN• `7sn 7 II ^aQr� CITY PARCEL SIZEIAPNJ' ry A- <br /> MNER'S NAME �I ` I ADDRESSQg <br /> RACTDR �—r <br /> PHONE/�r <br /> (JD S DDRESS PHONE <br /> .CONTRACTOR ����III ADORES 6 1L.,f�o +K+�PHONE I <br /> OF WELLVUMP: . NEW WELL REPLACEMENT WELL ❑ MONrTORING WELL N ❑ OTHER <br /> �� n ❑ INSTALLATION ❑ WELL SYSTEM WELL <br /> ❑ CROSS•CONNECT RiiP $A 0 VAPOR EXTRACTION WELLL# <br /> ❑New❑Repair H.P._ 2 DEPTH PIMP SEr+FT. FIRST WATER LEVEL. ��C! <br /> (PE OF P1MPI <br /> 11 ,��// O <br /> OUT-OF-SERVICE WELL ❑ GEOPHY61CgL WELL/ ❑ SOIL BORING_ 'f�y/(ij. � 1y, <br /> F-mSTRUCTION: <br /> C <br /> rENDEO USE TYPE OF WELL CONSTRUCTION SPECIFIC A <br /> CA710N5 <br /> ` <br /> aDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONDIA.OF <br /> .r-�� <br /> ,�yGCONDUCTOR CASING p �•. <br /> ,ONiESTiClpAIVATE 3d7 RAVEL pgCK1SFZE <br /> ATYPE OF CASINGISTEELMVC DIA.OF WELL CASING -_ i <br /> , p <br /> PlJBL1C/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL _ Y/ SPECIFICATION r <br /> ~ R <br /> GATIONIAG ❑OTHER GROUT SEAL INSTALLED BY 4g:.A,�TES GROUT BRAND NAME -/YI^•fJJJ�T` 0 <br /> R�CyYY��IE <br /> IONITORING GROUT SEAL PUMPED: <br /> /W. r_1 N. CONCRETE PEDESTAL BY DRILLER:0 Y.IgNo g <br /> 1 <br /> PROX,DEPTH LOCKING CHESTER BOXISTOVE PPE <br /> S:T Z <br /> 3POSED CONSTRUCTIONJDWLUNq METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER , <br /> :$Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE-WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND Lp4- t <br /> 3ULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:^I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH Sy I <br /> IS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> �OL.LOWiNG; 'I CERTIFY THAT IN THE RFORMANCE OF THE WORK FOR WHICH THIfi PERMrT IS ISSUED,I SHAL!EMP.OY PERSONS SUBJECT TO WORKMAW'i COMPENSATION LAWS OF <br /> r6! ORNIA•^ 'TpF� T VST IN ADVANCE FOR ALL REq{AR£D INiPECTIp!AT I20Y►4aS 2g. CpMPLETE DRAWING AT LOWER AREA DROVE � <br /> � Titie Oats � � E <br /> J <br /> PLOT PLAH[Draw to Sola}Scala ^to <br /> JNES OF STREETS OR ROADS NEAREST 7Q OR BOUNDING THE PROPEFITY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL 6YSTEM OR PROPOSED <br /> rfLINE OF THE PROPERFY,GIVING DIMENSIDN6 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> VIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> MRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> _-�... . ,.. .. - - <br /> ., .. .,.. -, ..... .,. '. .. <br /> 4 y1 �� ... ... <br /> l . ..� . . <br /> ............... <br /> P1, <br /> .... <br />