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APPLICATION FOR WELL►PUMP PERMITS <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERMS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201368 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS HERE By MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADDRESS/OR EA1PN# CITY ` PARCEL 812E/AWJ# <br /> OWNER'S NAME yyIY1�Ll.J (1�4L �Q,`1p�0"34 ���n S J ADDRESS J.t.�O�,yy1(V,1��ppAL�'I1 h E7-� PHONE 0 <br /> CONTRACTOR L N J l'� �OV��i NkIjYWU t ^G�➢�-N•T�, ADDRESS \��© (N I'1n(�(L�1'{�WT1:=LI.CCI�. O PHONE <br /> SUB CONTRACTOR —� ADDRESS LIC# <br /> � / PHONE J <br /> fNPE OF WELLIP ,LlUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I �❑(OTHER <br /> ❑ INSTALLATION 11 WELL SYSTEM REPAIR 11CBOSS-CONNECT REPAIR CL VAPOR EXTRACTION 0 <br /> N.11Rep.B H.P. DEPTH PUMP SET FT. , FIRST WATER LEVEL_ D <br /> RVPL OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BONNO R <br /> 11 DESTRUCTION: <br /> INTENDED UBE TYPE OF WELL CONSTRUCTION BPECINCATIONS 1 A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING `1' Lyl D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELJPVC DIA.OF WELL CASING D <br /> ❑ MBUCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME E <br /> ❑ MONITORING L GROW SEAL PUMPED: ❑Ya [IN. CONCRETE PEDESTAL BY DRILLER:❑Ya ❑N. S <br /> APPROX.DEPTH 1,� �'{ LOCKING CHESTER BOX/STOVE PIPE- <br /> PROPOSED <br /> l S <br /> PROPOSED CONSTRUC NTO�/mBWNG METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 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 WOO(POR WHICH <br /> THIS PERMIT 18 ISSUED,I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WOROAAN'e COMPENSATION LAWS OF <br /> CALIFORNIA l 71� C T MUSTICt�24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT 120{146844222.,YCOMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> elen«I x ! 1_ nn. a�X�>�1 C^4Y)k—� D.t. IL - .. <br /> PLOT PLAN ID,.w to Sinal Sul. 't. <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 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 /> 3. DIMENSIONED OUTUNF.S 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 WALK& ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .......n.... ....:.. .9.. <br /> ENT use ONLY <br /> Appllellft.A.eeptM BY a D.te <br /> Ara <br /> Grout Impectlon BY D.I. Pump impatlon BY paa <br /> Datruetl.n I.Patlen BY D.te <br /> Com,rl.W <br /> ACCOUNTING ONLY: AIDS FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECIUFMASH RECEIVED BY DATE PEIIMPUSERVICE REQUEST NUMSEIt INVOICE <br />