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APPLICATION FOR WELLIPUMP PERMIT S7 17 <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOADUIN ST., STOCKTON,CA 96201388 <br /> (209) 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION 15 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 WITH SAN <br /> J WIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3(AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> J WDRESS/OR APN/i C/./2-i ��i Zir«" ("-K CITY ��`cwt \A� SIJ-� <br /> / ((�Z PARCEL SIZE/APNI (y (y <br /> OWNER'S NAME�SAJ%1 L{::5 Y2 �; i �� ADDRESS / 3 I�l'��.1.r �� J.(�-�1_. PHONE AL. (.- <br /> _D <br /> /I / <br /> CONTRACTOR i_).¢t'CA.y ,fADDRESS S'�/�'i� LIC/ 6- f 1 PHONE#/ � <br /> S :ONTRACTOR ADDRESS UC.F PHONES <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL S ❑OTHER <br /> ` ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑CBOSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL• J <br /> A�,-C�/t1 ❑New aR i, N.P. -Vt) DEPTH PUMP SET - ( FT. FIRST WATER LEVEL O <br /> R :OF PUMP) <br /> ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL/ ❑ SOIL BORING g <br /> ❑DESTRUCTION: <br /> 11 <br /> MED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> C IDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> [,-150MESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASING D <br /> 11PPUBLICfMUNICIPAL 11DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> L ',RIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> C ONrTORING GROUT SEAL PUMPED:❑Ys ❑No CONCRETE PEDESTAL BY DRILLER:[1Y- ❑Ne S <br /> A mZ X.DEPTH LOCKING CHESTER BOX/STOVE PIPE 5 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I 1 :BY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND ll� <br /> RI .ATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH W <br /> TI 'ERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SURCONTRACTINGSIGNATURE CERTIFIES <br /> T HFFOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of <br /> CALIFORNIA.)' FIE,APyP,LICAN <br /> X T MUST CALL 24 HOURS IN ADVANCE FOR ALL)REQUIRED INSSPPECTION&AT 12OS14641 423. COMPLETE DRAWING AT LOWER AREA PROVIDED.. / �f <br /> SI, I J( CT l'/C� 1/L�1�J '/'/Nltle /i w✓✓ D.(e /f' J f�l`- .J <br /> PLOT PLAN 0—to ScNel Scels le <br /> I._.MES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROFUSED <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 WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 41 <br /> 1. <br /> DEPARTMENT USE ONLY <br /> Applicatlon Accepted By D t A 1 V- <br /> G—I-pmt,on BY Dela Pump In.pectlon BY LC Dete <br /> Dm pon I-peotlon BV Dete <br /> Cori I.: <br /> OUNTINO ONLY: AID/ FACJ <br /> PE CODES FEE INFO AMOUNT REMITTED JHIC CASH RECEIVED BY DATE PERMITISERVICE REQUEST N(1MBER INVOICE <br />