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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOA(IUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ►,{� � P 0 BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 56201-388 <br /> U (209)468.3420 <br /> X14 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TT4Goah) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STAND S OF SAN JOAQACOUPIUBIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVJ$10,�L�.(�,.v'AJ'�JOB ADDRESSOR APNR 67 PARCELS -..- I/I1 R//7'�r?OWNER'S NAME ADDRESS )7�D�%C��((JJ}}77PHHONE JCONTRACTOR ADDREUC'� TSUBCONTRACTOR ADDR (ICJ PHONEJ <br /> TYPE OF WELL/PUMP: NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL J ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL J ✓ _ <br /> ❑Naw❑R.P.Ir H.P. 24 DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> (TYPE OF PUMP( E3 -0 [3 SOIL BORING 8 <br /> OUTFA SERVICE WELL ❑GEOPHYSICAL WELL *` <br /> ❑DESTRUCTION: 1 <br /> INTENDED USE TYPE OF CONSTRUCTION SPECIFICATION /� f A <br /> 11 INDUSTRIAL PEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING I ill D n <br /> rIR <br /> ❑r��PUBLI^C/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ SPECIFICATION R <br /> Iid- RIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY C GROUT BRAND NAME E <br /> ❑MONITORING GROUT SEAL PIMPED:❑Y- CONCRETE PEDESTAL BY DRILLER: r No S <br /> APPROX.DEPTH LOCKING CHESTER SOx/STOVE RPE S <br /> PROPOSED CONSTRUCTION/DRIWNG METHOD:MUD ROTARY AIR ROTARY/ AUGER CABLE OTHER <br /> 1 HEREBY 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 <br /> REGULATIONS 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 <br /> THIS PERMIT <br /> IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SU"ONTRACTING SIGNATURE CERTIFIES <br /> THE FOLL4THE <br /> TIFY THAT IN THE P RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S VIDED.COMPENSATION LAWS OF <br /> CMIFORNT MUST CALL URB 1 ADVANCE FOR ALL REQUIRIED INS NS AT-1208)4SSJ42a.COMPETE DRAWING AT LOWER AREA PROVIDED.Slerwd% TRI.PLOT N(Dr to SW.)Sul.1.NAMR ROADS NEAREST TO OR BOUNDING T P OPEKTY. 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 /> Ur <br /> DIMEN&ONED OURINES 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 /> NGV16 I <br /> _ <br /> ` 1 <br /> DEPARTMENT USE ONLY i Iy' <br /> pit,d-A..p[.d BY D. /^ �� A✓a 12 L-^7 G <br /> au[ropection BY D.nPumP Irop.cdon BY Data`-7 <br /> [rucdan Irop.cti.n By <br /> .t. <br /> msnU: <br /> ACCOUNTING ONLY: AIDJ // FACJ <br /> PE CODES FEE INFO AMOUNT REMITTED (cHEC ASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> :i I'x.CD <br />