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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN JOAQUIN ST,STOCKTON,CA 96201-388 <br /> (209)468.3420 <br /> �� lee Y��yr NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> [ C F` Y (Complete in Triplicate) <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 SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDDS//pF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNA &I' ( CITY PANEL SIZE/APNB <br /> OWNER'S NAME <br /> '^�� ADDRESS S�Wd PHONER <br /> CONTRACTOR (]L7 ,g��C ADDREB$ wy LIC, JC PHONE . SI- <br /> SUB CONTRACTOR ADDRESS LICA PHONE A <br /> TYPE OF WELLIPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL A ❑OTHER <br /> ❑INSTALLATION ❑WELL/�A'STEM REPAIR ❑CROSS-CONNECT REPAIR 13 VAPOR EXTRACTION WELL F <br /> ew <br /> � <br /> ❑NRepelr DEPTH PUMP SETZI4JFT. FIRST WATER LEVEL-U C J O <br /> (TYPE OF PUMP) /I— <br /> r-T ❑OUT-OF-SERVICE WELL C1 GEOPHYSICAL WELL# ❑ SOIL BORING B <br /> bJ DESTRUCTION: <br /> INTENDED UBE TYPE OF WELL CONSTRUCTION SPECMdCAT10N8 A <br /> 13 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEUPVC DIA.OF WELL CASING D <br /> ❑PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> 0 MONITORING _ GROUT SEAL PUMPED:❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Y. ❑Ne 5 <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONMAILUNG METHOD:MUD ROTARY AIR ROTARY AUGER CASLE OTHER <br /> I 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 IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CE THAT IN THE PERFO NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM ATION LAWS OF <br /> CALIFORNIA.' CA MUST CALL 24) IN AN)CE FOR ALL REQUIRED INS PTI/ONS AT 120814884425.COMPLETE DRAWINO AT LOWER AREA PROVIDE '— <br /> S19-d X �.-S E s// Title 9 <br /> `�— D•te <br /> PLOT PLAN(Dr—to Soelel SeMe 'to <br /> 1.NAMES OF STREETS OR TOADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> O <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 /> r i9 Q ro tL <br /> �r <br /> 5 ale <br /> / <br /> DEPARTMENT USE ONLY <br /> Applieetien Accepted BY /oc <br /> > C <br /> /1p• Aree �j� <br /> Grout Irnpectlon By Pomp lmwtion BY <br /> De umtbn Impeetien BY Dete <br /> Comments: <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED EC ABH RECEIVED BY DATE PETWIITM E REGUEBT NUMBER INVOICE <br />