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APPLICATION FOR WELLIPUMP PERMIT <br /> tAN JOAQUIN COUNTY PUBLIC HEALTH SERV' ; <br /> ENVIRONMENTAL HEALTH DIVISION <br /> h <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br /> (209) 468-3420 <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4,j <br /> 1Compipt6 in Triplicate) I _ <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 MAD OMPLIAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115 3 AND HE TDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTHSERVICES.ENVIRONMENTAL HEAL MS101 <br /> JOB ADDRESSOR�AIPN;R 1 y 1 w*aVf CTrI' PARCEL S>Z�AJp/y,� q Q <br /> OWNER'S NAME /7 rzA <br /> L �— / ADORES 8 <br /> CONTRACTOR >� ADDRESS <br />'I <br /> SUB CONTRACTOR ADDRESS LLC# PHONE N <br /> TYPE OF WELLlPUMP: NEW WELL ❑ REPLACEMENT WELL MONITORING WELL W_. `// ❑ OTHER <br /> INSTALLATION ❑ WELL SYSTEM REPAIR El CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ - J <br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. .FIRST WATER LEVEL - Q - <br /> (TYPE OF PUMP [3OUT-OF-SERVICEWELL ❑GEOPHYSICAL WELL# � SOIL BORING!L, -l � H <br /> D <br /> DESTRUCTION: "L <br /> INTENDED USE - TYPE OF WELL CONSTRUCTION SPECIFICATIONS A C <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM I DIA.OF WELL EXCAVATION 03 DIA.OF CONDUCTOR CASING <br /> © DOMESTIC/PRIVATE GRAVEL PACK/SQE TYPE OF CASING/STEEUlPVC DIA.OF WELL CASING .V JD13PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑ IRRIGA710NIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> 0 .ITORING IJ�+• GROUT SEAL PUMPED: e• ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes ❑No S <br /> DEPTH LOCKING CHESTER BOXISTO S <br /> PROPOS®CON8TRIICTIONlDWWNO METHOD: MUD ROTARY AIR ROTARY AUGER' CABLE OTHER <br /> I HMBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUWN 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 WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOR97AA14'9 COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLIC T MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED/IINBP.ECTIIONS AAT�(/20991 4/688.3444233..fCOMPLETE DRAWING AT LOWER AREA PROVIDED. Qom+ <br /> Slpneo /• 'ntio GL../.l�VSfX'J.�T1 Orta /lr 7` /J <br /> PLOT PLAN(Draw to Seale)Seale '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 /> .-----.- - --.. - ... .. ., .. .. .. <br /> Ami <br /> E <br /> . ......- ...... ..... ....... .. . <br /> .: ..„. <br /> .,.., ..,... ., <br /> DEPIWTMLTIT USE ONLY ' <br />'I Applitatlon Accep[ed BY Date / Ares - <br /> Grout Inspection BY Date Pump Inspee[lon BY Date <br /> Dwtruetlen Inspection BY Data <br /> Comments: <br /> i <br /> ACCOUNTING ONLY: AIDE FACT <br /> ED SY DATE p9WI <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKN/CASH RECEIVIT/SEFtVICE REQUEST NUMBER INVOICE <br />