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APPLICATION FOR WELL,/PUMP PE <br /> S JOAQUIN COUNTY PUBLIC HEALTH ES <br /> ENVIRONMENTAL HEALTH DIVISIC,.. <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in TripikNo) <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 WTTH SAN <br /> JOAQUIN COUJITY <br /> QF <br /> /zJELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. �f <br /> JOB ADD SS OROAPNI �J CITY PARCEL SIZEIAPN#' [{e <br /> OWNER'S NAME ADDRESS 27t)? ( / PHONE 1/1`4001SC. <br /> CONTRACTOR ADDRESS ( dC7 PHONE <br /> SUB CONTRACTOR ADDRESS 1 UCI PHONE I <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> ❑New❑Reoelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> R VPE OF PUMP) �/ <br /> ❑ OVT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL# LL'1 SOIL BORING g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 2 ,I DIA.OF CONDUCTOR CASING A/A. p <br /> ❑ DOME 9TICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIT VC/ DIA.OF WELL CASING O <br /> C1 PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL Imo" �ti SPECIFICATION l B <br /> 1❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> D F <br /> MONITOnINO ,/L� 1 GROUT SEAL PUMPED: ❑Ye. C1 No CONCRETE PEDESTAL SY DRILLER:❑Yee ❑Ne S <br /> APPRO X.DEPTH "O LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTION/DIOLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER__ <br /> 1 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA." T1 CANT MUST C RS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001484-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed X t/L J` Thle : l J 0e1e <br /> PLOT PLAN(Drew to Seelel S.M. to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR 13OUNNNO THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,DIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNES AND LOCATION OF ALL EX19TING AND PROPOSED S. LOCATION OF WELLS WrTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ... .: ... <br /> .. .. .... <br /> DEPARTMENT USE ONLY ( <br /> AoPlleellen Aeoeoted BY `"� �` Date_ / Arm <br /> Grout Imoeellen By��^�".V,\r%V Deb Pwv hwpoetlen By Date <br /> 0—f—tien trwP-0—BY Dete <br /> Comme..tc <br /> I AC.NTINO ONLY: AID# FACJ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKNICASH RECEIVED BY DATE P81MIT/SERVICE REQUEST NUMBER INVOICE <br /> 9 D 23 1 <br /> Pub.Health Serv.-Enviro.173(1/97) <br />