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APPLICATION FOR WELLIPUMP PERMIT <br /> J✓SAN JOAQUIN COUNTY PUBLIC HEALTH Silln4S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> loomp <br /> tel <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT TIAND/ORI INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 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 ADDRESSOR APNI G 10-1"S4 . CITY Y 0 t <br /> PARCEL,IZEIAM, <br /> OWNER'S NAME� ' r , �u' <br /> !` ` ADDRESS �/ (.. / n- PHONES p <br /> CONTRACTOR l �'�' `..l U\�,h-+IMG-�Y3, �1(Y+.+lfi. I�ZO I.OMWITK tl � Vic/ 6S�.RJ� A ^J y <br /> DDRE86 PHONE -31 il7-r0 <br /> SUB CONTnATOR I� t j I �IQ,I C� fir'•. c 1 <br /> v ADORESB lKf <br /> PHONE f <br /> TYPE OF WELLIPUMP' ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f <br /> 1:1 INSTALLATION 11 WELL SYSTEM REPAIR ❑ OTHER <br /> ❑ CIR088tONNECT REPAIR ❑ yppOq E%TRACTION WELL/ <br /> ❑N.13RepNJ <br /> r H.P. DEPTH PUMP BET <br /> DYPE OF PUMP —_FT, FyIH,BT WATER LEVEL 0 <br /> OUT -SERVICE WELL ❑ GEOPHYSICAL WELL f 1`�-� SOIL BORING <br /> DESTRUCTION: 11 -0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONA <br /> DIA.OF CONDUCTOR CASING <br /> . ❑ DOMEBTIC/PNVATE 13 GRAVEL PACK/SIZE TYPE OF CASINO/BTEEUPVC DIA,OF WELL CASINO 0 <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEND <br /> DEPTH OF GROUT SEAL SPECIFICATION —� <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> ❑ MONITORINGE <br /> /41 GROUT SEAL PIMPED: [3 Y. [IN. CONCRETE PEDESTAL BY DRILLER:❑Ym ONO S <br /> APPROX.DEPTH LOCKING CHESTER BOX/BTOVE PPEa S <br /> MOPOSED CONSTRUCTIONR% W <br /> ENG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHE r/fK \ ?VCk <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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 WOW FOR WHICH <br /> THIS PERMIT 16 ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR',HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLO NO: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA. THFIAPPLICANT MUST CALL 211 HOIM6 IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120111/Slt 122. COMPLETE DRAWING AT LOWER AREA PRO" D. <br /> 8lprndX 'li`. TIB. I fl <br /> P 2 <br /> PLOT PAN[Dr.to SOY.I BpN. 'alO� j <br /> 1. NAMES OF STREET,OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR MMSED <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 6. 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 /> I© 6, Sit <br /> b <br /> 60 10 <br /> r F <br /> l <br /> ... / DEPMTMENT USE ONLY <br /> Appllc.elon Accepted Br " T – O.e. l Arr <br /> Grow Irnpecelon By D.te Pump In.p.c0en By D.t. <br /> Dstrwtlen Irnpxel.n Br De. <br /> COmmenH: <br /> ACCOUNTING ONLY: NDS FACS <br /> PE CODES FEE INFO AMOUNT REMITTED ,CHECKINCASH RECEIVED BY DATE FrERM1TAIERVICE REQUEST NUMBER INVOICE <br /> r <br /> / 7e <br />