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APPLICATION FOR WELL►PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. 80X 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (109) 469.3420 <br /> 1110111-REFUND BLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT'TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTYPUBLIC <br /> HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/On APN/ (Q 490 CIT" <br /> PARCEL SIZE/A1'fJ/ <br /> OWNEn'S NAME � V S AODnESR ! -q/ -2\ Z PHONE <br /> CONTRACTOR_ r^V I !. � d -j� C AODnEae p -�LICI 3 9 7�y <br /> U PHONE <br /> aVB CONTRACTOR ADDRESS LICI <br /> PHONE 1 <br /> TYPE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> FJI INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> New 13RepairH.P. DEPTH PUMP SET�FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> ElOUT-orSEnVICE WELL ❑ GEOPHYSICAL WELL I ElSOIL BORING y '� <br /> ❑DESTRUCTION! O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> A <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO <br /> D <br /> DOMESTIC/I'IRIVATE ❑GRAVEL PACKIBIZE TYPE OF CASINO/STEEVT'VC OLA.OF WELL CASINO <br /> D <br /> PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROAT SEAL SPECIFICATION <br /> 8 <br /> IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yea [IN. CONCRETE PEDESTAL BY DRILLER:❑YM ❑No S <br /> APPROX.DEPTH LOCKING CHESTEn BOX/STOVE PPE S <br /> PROPOSED CONS TMMC TIO NMIRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Q <br /> 1 HEREBY CERTIFY T14AT 1 HAVE PREPARED T1418 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND (v'j <br /> REGULATIONS OF TIRE SAN JOAOUIN COUNTY. HOME OWNER On LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PFRFOnMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,- CONTRACTOn'B HIRING On PUB-CONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING; 'I CERTIFY THAT IN TILE PERFOnMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF <br /> CALIFOnNI APP CANT =CALL URS IN ADVANCE FOR ALL REOIARFD INSSPPIECT//o NS AT t2001 481114423. COMPLETE DRAWING AT LOWER AREA PROVIDED <br /> 8lpne I X Tltlw 2 / P S <br /> Date <br /> PLOT PIAN(Draw to S-1e1 Scale 'to <br /> 1. NAMES OR STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OLFILINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED RIPTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING PROPEnTY. <br /> ... °.. . <br /> . <br /> r <br /> l <br /> ill <br /> _TK Q <br /> :wet/ <br /> Q0 <br /> s <br /> ....;. .. <...... ... :. .. . : . :.......... .. .. ...... � 195E <br /> . .........:. ..:. . :. ..:. <br /> :... <br /> "UBLIC HEALTH <br /> DEPARTMENT USE ONLY <br /> Application Accepted By_ n <br /> C D.Iell; A4 -7 Area <br /> Grow Impecllon By Data P—p Inapectlen By 1 -r <br /> Dale � f� %-3 <br /> On.lrlrcllen I-prllon By <br /> Data <br /> Corn—I.: <br /> ACCOUNTINO ONLY: AIDI FACT <br /> PE CODES FEE INFO AMOUNT REMITTED HECK I ASH RECEIVED By DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> gc0 <br /> Pub.Health Serv.-Enviro.173(3/96) <br /> /r <br />