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APPLICATION FOR WELLIPUMP PERMIT
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> F ENVIRONMENTAL HEALTH DIVISION
<br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388
<br />' (209) 468.3420 I y
<br /> NOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED
<br /> ICompl9t9 In Trolkst9l
<br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DEE CRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN
<br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUSLIL HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.
<br /> JOB ADpRE9SIOR APN# I LQI2 1�Am ma f LZ nt •,•,.__ cttr t, i! PARCEL SIZElAPN#
<br /> OWNER'S NAME: Pcorlucl.. ADDRESS Z►5 ) . PHONEQ
<br /> CONTRACTOR_W c)orA 11 (xrA ADDRESSL-0, 0)L73n. REioVI,S�'R LICK LS I'S OI WfiONE �_�.��y"-ioo
<br /> SUB CONTRACTOR ADDRESS UCN PHONE N
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<br /> TYPE Of WELLJPUMP: NEW WELL ❑ REPLACEMENT WELL -
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<br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR 'li ❑ VAPOR EXTRACTION WELL N
<br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATFA LEVEL O
<br /> (TYPE OF PUMPI 1�6
<br /> 1. ❑ OUT-OF•S RVICE WELL, ❑ GEOPHYSICAL WELL N II '� ❑ SOIL BORING g
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<br />' INTENDED USE TYPE OF WELL 604BTRUCTION SPECIFICATIONS j �I r1 A
<br /> ❑ INDUS7ITIAL ❑OPEN BOTTOM DIA-OF WELL EXCAVATION 1{]��'- Ir 'F DIA.OF CONDUCTOR CASINO I`,r ►nW-7) p fff
<br /> t ❑ DOMESTICIPRIVATE GRAVEL PACKISIZE_._3�j'LY1� TYPE OF CASINGISTEFUPVC JJ-110 �IC� �.� DIA.OF WELL CASING tl p
<br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL '�' II 'E SPECIFICATION T A }
<br /> ❑ 1RRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME Of Y'1 E
<br /> MONITORING (��J /_ GROUT SEAT.PIIMPE0: 1 Y. ❑No i CONCRETE PEDESTAL BY DRILLFR:❑Yee ❑N.NA S
<br /> I APPROX.DEPTH �4' LOCKING CHESTER$OXISTOVE PIPE r• S
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<br /> PROPOSED CONOTRUCTIONlUWLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER
<br /> I 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;'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHFCH �
<br /> THIS PERMIT IS ISSUED,16HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN
<br /> COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES I
<br /> THE FOLLOWNG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-9 COMPENSATION LAWS OF L
<br /> CALIFORNIA.' THE APPLICANT UST 24 HOURS IN ADVANCE FOR ALL REaU1RED IN6FECTIONG AT 1,2091 408,3473. COMPLETE DRAWING AT LOWER AREA PROVIDED, r
<br /> Signed X Title I, '� Date G
<br /> T PLAN IDraw to Boole)Seele
<br /> t. NAMES Of STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED
<br /> r 2, OUTLINE OF THE PROPERTY,DIVING DIMENSIONS AND NORTH DIRECTION. }
<br />{ �� EXPANslON OF SEWAGE DISPOSAL SYSTEMS. r
<br /> 3- DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.
<br /> j STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. 1� ON THE PROPERTY OR ADJOINING PROPERTY. 1
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<br /> DEPARTMENT USE ONLY }I
<br /> Appllcatlon Accepted By Y �!- v y •'° Date it '
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<br /> Grout ImI>«tlen Ry Deee Pump Impaction By Date
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<br /> O—Ouctlon Impaction By }} it bate -k
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<br /> ACCOUNTING ONLY: AID# FAC#
<br /> PE CODEJi FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE i�, PEWNITfSERVICE RERUE$T NUMBER INVOICE
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