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1 APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX-aw 304 EAST WEBER AVENUE,STOCKTON,CA 95201-W <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in TripliatE) <br /> APPLICATION IS 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 WITH S <br /> JOAQUIN COUNTY DEVELOPMENT TITLE, <br /> CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSI OR APN/ ---1`'Ftl ,S eTTS -f E, �(�}� CITY �J'fJ(�j�T-/1/L/. C PARCEL SRE/APNI <br /> OWNER'S NAME. 4';- -�P63 a6lft (_0*1 PALP1 ADDRESS 710 E CJVLN SAJ �4..NE I p� <br /> CONTRACTOR JP 1M- �Aj Q'ST I ADDRESS ST CAP,}'ai MI}I.I, CI PHONE / <br /> R`(� A Fi (> <br /> / \/� � <br /> SUB CONTRACTOL,F(.I IA,I`(yi ! ADDRESS C 77�-�! <br /> o A IJC/J�7 PHONE 9 b45-- <br /> ' TYPE OF WELL/PUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONTTORING WELL ICG ❑OTHER <br /> I <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL/ <br /> ❑N-❑F+,.1, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL I ❑ SOIL BORING <br /> DESTRUCTbN: t <br /> 2`{-PJc AkCQ. 111CUV . Wf l.S . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION{ <br /> 11 <br /> ❑INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION �I� DIA.OF CONDUCTOR CASINO <br /> ❑DOMESTIC/PNVATE ❑GRAVEL PACK/SRE TYPE OF CASING/STEEUPVC /_/I L'VC- DIA.OF WELL CASING 2 <br /> 1 ❑PUSUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL \R+,�+.3�52 SPECIFICATION <br /> �❑IRRIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY ✓ LI.EI-S • GROUT BRAND NAME_ <br /> t L7"MONRORING -7 / GROUT SEAL PUMPED:0 Yr ❑N. CONCRETE PEDESTAL BY DRILLER:QYw ❑No <br /> APPROX.DEPTH N ! 0 LOCKING CHESTER SOX/STOVE RPE <br /> PROPOSED CONSTRUCTION/DPoWNO METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HE"ESY 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 A <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 WORK FOR WH. <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIF <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS <br /> CALIFORNIA.- TH CANT MUST CALL 34 HOURS IN ADVANCE FOR ALL REGUIRW INSPECTION/AT(201)400-2421.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slprrdx TIn. ,�fWIGt`r`IFf-1C D.t. (Z/{�t A <br /> It <br /> t J PLOT PLAN(0—to Boole)Sul. '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 DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES 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 WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> S <br /> 6 ..Se:er.. C-NC4-0SS; <br /> l <br /> f <br /> 1 <br /> 1 <br /> I <br /> r <br /> i I / DEPARTMENT WE ONLY <br /> Appli-1 rt A-e Ptd By.../� +�/� D.t. A-1-46) <br /> , <br /> Grout Impwtlon By D.te Pump In.p.otlon BY D.t. <br /> Dst-tion 1 apwtlon By D.t. <br /> ACC OUNTWO ONLY: AIDI <br /> /^- <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK/CASH RECEIVED SY DATE ►PIiMIT/SERICE REQUEST N1SN19t INVOICE <br /> 7;; 00,h&o <br />