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APPLICATION FOR WELLIPUMP PERMI <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br /> (209) 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> ICompkn IN Triplint4l <br /> APPLICATION IS HEM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOP A IT ,CH EA 9-1115 3 AND T E Si DARDS OF SAN JOAQUIN COUNTY PUBU��C11/HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AGGRESSION APNI CITY U�'L PARCEL SlMAPNI <br /> OWNER'S NAME / ADDRESS PHONEI <br /> r <br /> CONTRACTOR ,�{ �ADDRESS G L1Ci PHONEJ <br /> SUB CONTRACTOR � ADDRESS 11Ci PHONEI <br /> TYPE OF WELLR'UMP: �r❑l NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL i ❑ OTHER <br /> 5uk 6J MWELL STALLATION ❑ SEMREPaR ❑ CROSS-CONNECT 4EPAIR ❑ VAPOR EXTMCTIONWELLI J <br /> N ❑R.P.Ir H.P. DEPTH PUMP SET FT. FIRST WATER Um-7I <br /> O <br /> (TYPE OF PUMP) <br /> � � ❑OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> p^❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> WPOOMESTICIPNRAV <br /> VATE ❑GEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF MU.CASING O <br /> /❑ FUBLICRIUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG Cl OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: 11 Y. 0 N CONCRETEPEOESTALSYDRILLFR:❑Yr []No S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONIDRILUNO METHOD: MUD ROTARY MR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OMNANCES.STATE LAWS.AND RULES AND S <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(FOO WHICH <br /> THIS PERMIT IS ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: .I CERTIFY THAT IN TIE ERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA. H APPLICANT MUST CA 24 NOL 0 N ADVANCE FOR ALL REQUIRED INSPK NI/AT(20II HNBJ M. COMPLETE DRAWING AT LOWER AREA PROVIDE . <br /> sl'n Xday TIB. ( - O.te <br /> PIDT PLAN IDre to SoNel Sulo -to <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 DIMENSMONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS VRTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> JCA°ROE I <br /> JUN 2 3 1995 <br /> J SAIN-U. uu,NC.OUNTY <br /> PUBLIC HEALTH SERVICES ' <br /> ENVIROMMIENTAL HEALTH DIVIt ON <br /> C <br /> DEPARTMENT WE anLr - <br /> APpllutlu Acoeptetl Br�E'i LI"y <br />