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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION �� <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (COMPIGIS <br /> I <br /> APPLICATION 13 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTTRUCTARNDIORCINSTALL THE WOW DESCRIBED.THIS AMICAMN IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEV PPUENT TFFLE,CHAPTER 8-1 115.3 D THE TANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH DIVISION. <br /> ENVIRONMENTAL HEALTH DSION. <br /> JOB ADORESS/OR AP'N /� ( U/1 _ -}/'S f )_6- 005 <br /> PARCEL SIZE/AF?JI <br /> OWNER'S NAME A BB <br /> Q <br /> CONTRACTOR - ADDRESS PHONE•UCI� / <br /> 1`IRONE <br /> SUB CONTRACTOR <br /> ADDRESS UC/ PHONE <br /> It <br /> TYPE OF WELLIPVMP; NEW WELL ❑ REPLACEMENT WELL ❑ MONPTORINO WELL# ❑ OTHER <br /> `Y• ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> J <br /> Now❑RoPN, ".P. 2-s DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> R VPf OF PUMP) O <br /> ❑ <br /> DESTRUCTION: OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING <br /> ❑ <br /> B <br /> INTENDED USE TYPE O CON{TgUC TION fPECIFIC ATIONS <br /> ❑ INDUSTRIAL DIAA <br /> OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO <br /> ElPW <br /> DOMESTIC/ VATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEt/PVC /�1 it D <br /> .OF WELL CASINO_ L.- 0 <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> T�E,� R <br /> ua IRRIGATKTN/AG ❑OTHER GROUT SEAL/ INSTALLED By GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Y« o , <br /> CONCRETE PEDESTAL BY LLER:❑y« ❑No S <br /> APPR07(_DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> 5 <br /> PROPOSED CON{TRUC TIONlD1IlLIN0 METHOD: MVD ROTARY AIR ROTARY AVOER CABLE <br /> OTHER <br /> 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS""-"CATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 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:•1 CERTIFY THAT W THE PERFORMANCE OF THE WOR(FOR NWHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PC so 8 SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR RU"ONTRACTNG SIGNATURE <br /> THE FOLLOWING: '1 CERTIFY THAT N THE PE ANCE OF THE WOW FOR WHICH THIS PERMIT I8 ISSUEDCERTIFIER <br /> ,1 SHALL EMPLOY PERSONS SUBJECT TO WOIIIONAN'{COMP4}If ATION LAWS OF <br /> CALIFORNI?8TFTS <br /> HE CANT MUS CALL 24 1 DVANCE FOR ALL REGUMED INi N1 AT 20{1 400-11423. COMPLETE DRAWING AT LOWER AREA PROVIDE[).ft—d X <br /> Tltls <br /> --p Data <br /> ►LOT PLAN —to ScN•I Be•I• to <br /> 1. NAMES OR ROADS NEAREST TO OR BOUNDING THE PERTY, <br /> 2. OUTLINE OF TELE PROPERTY,01%"M DIMENSIONS AND NORTH DIRECTION. EXPANSION 4. LOCATION OF HOUSE E DISPO DISPOSAL SYSTEM Oq R'ItOT'OSED <br /> 3. DIMENSIONED OVTLINFB AND LOCATION OF ALL EXISTING AND PROPOSEDF SEWAGE DISPOSAL SYSTEM{. <br /> STRUCTVREB,NCLW <br /> VDING COVERED AREAS SUCH AB PATIOS,DVEWAY8,AND WALK B. {• LOCATION OF WFLLB WHHN RADIVf OF ONE HVNfN1ED FIFTY FT. <br /> ON THE PROPERTY OR ADJOINING PROPERTY. <br /> APR 11999 <br /> SEu,:.:EGAUUtN CLIUN-`r <br /> ;.... E.. PLIMIC HEAL.Til SENPE rt <br /> 1 <br />