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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 9520" <br /> (209) 468-3420 COPY <br /> NDN•REFUMDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Compkis In THpliCIlb) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRN SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> O� - �`���f C1 rec'�7 / �L� CITU C�ICLb � CI/ vs-PARCEL SIZE/APN/ -L C% [- <br /> JOS ADDRESS/OR AP.. i <br /> / I x ADDRESS 15di <br /> F'HONE f 19 <br /> OWNER'S NAME l�f�'' � L 1 Lh L� / (f/ 5��LI <br /> CONTRACTOR <br /> ADDRFSS E lJ`U/�/, y LIC7 PHONE <br /> SUR CONTRACTOR ADDRESS LIC. PHONE. <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL. ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ❑NewRepwlr H.P. _ DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> RVPE OF PUMP) 9 <br /> ❑ OUF-O -SERVICE WELL ❑ �'°PHVSICAI.WELL ❑ SOIL BORING <br /> INIENDEO USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPFN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEFLIPVC DIA.OF WELL CASINO D <br /> ❑ PURLICIMUNICIPAI ❑DRIVFN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED! ❑Vee ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Vw ❑No S <br /> APPROX.DEPTH LOCKING CHESYER BOX/STOVE PIPE S <br /> PROPOSED CON STRUC TIO NID LUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I Hf9ERV CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> RFGLR ATIONS OF THE SAN.JOAQUIN COUNTY. HOME OWNER OR I ICENSFD AOFNT'S SIGNATURE CERTIFIES THE FOLLOWING! '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> 7HIS PfnM1T IS ISSUED,1 SNAIL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR OUR SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUF.D.1 SHAH EMPLOY PfnSONR BURJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAI IFORNIA.' THE PPUCANT MUST�/1LL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSP[CTIONS AT 12061 SdYJ4123. COMPLETE DRAWING AT IOWER AREA PROVIDED. <br /> Slprwl X � <br /> /tllt Dote <br /> PLOT PLAN IDrew to Scdwl ScNs 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WFTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> J STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> CJ\5 <br /> ,1 <br /> J <br /> `1 <br /> I <br /> PAYMENT <br /> -Zji RECEIVED <br /> �y JUN 51997 <br /> SAN JOAOI LIN COUNT\ <br /> F : US <br /> r-NVHNd FN1AI jIMI H INV SIGN <br /> nFPAPTMFNT 116E ONLY <br /> ApPllrwtlon'AeewPterl Rv ( , � -. �1'�"�`/ '-+i Dwl T Ar ww L <br /> Grmtl Irnprrlion By <br /> DotePtrrnp Inwpe.tlon By c L'LIAr Ile 1-1 Date <br /> D-ftmtl..Irnpeotlon By - Dwlw <br /> CeTTorHw' <br /> ACCOUNTING ONLY: AID/ FAC. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECk.ICAS1/ RECEIVED By DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />