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4PPLICATION FOR WELUPUMP PERM" <br /> SA )AQUIN COUNTY PUBLIC HEALTH SE IES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete IR TFipficab) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TIIIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TrTLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APNI VCS 7 L L,_), CITY AIA d!- Eec 't <br /> PARCEL SIZE/APNI 2 -� <br /> OWNER'S NAME ADDRESS :�C)7[— /,{iIryC�<!�GYr! T� <br /> .r .�IiE7. /�a7/IL PHONE( `t-G/L.;:.•''%-`T>7j <br /> CONTRACTOR �� 67iLe c7t/Z" h4[-7 '� ADDRESS 5' r9 Slacel' 1 y^ UC+1 71(1 PHONE I ! <br /> 7Z— M <br /> SUB CONTRACTOR ADDPES8 UCl PHONE/- <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRTORING WELL IF ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> ❑New❑Ftepalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP( <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLI SOIL BORING g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A - <br /> I <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �1 DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PnIVATE ,❑/GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D <br /> El PUBLIC/MUNICIPAL I:OnIVEN DEPTH OF GROUT SEALAA SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY j r1` Cr GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yee [INo CONCRETE PEDESTAL BY DRILLER: Yea bNo S <br /> APPROX.DEPTH - LOCKING CHESTER SOXISTOVE PIPE /` S <br /> PROPOSED CONST'AUCTION/DRRLUNG METHOD: MUD ROTARY AIR ROTARY_ AUGER CABLE OTHER C <br /> 1 HE-EBY 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 ANO <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 WPIICH <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 CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOnK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN01ATTON LAWS OF <br /> CALIFOR=A=UFIS IN ADVANCE FOR ALL REGUIRED\INSPECT11ION/AT 12011144111-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blpnwd)( This l �,`1.�- L Data <br /> PLOT PLAN(D+ to Bc alel Scale 'to <br /> I. NAMES OF STREETS On ROADS NEAREST TO On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PnOPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PRO'l'OSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTUnES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY" <br /> ?... .. <br /> l 4Llt�( VIV <br /> DEPARITMENT USE ONLY <br /> Appllcallon Accepted By (7 rDa1a��T_Area <br /> Grout Impecllon By l l 6' Date �I Ito Pm p In7pectlon By Date <br /> Dale <br /> G-tnrcllon I-r,-Ilon By <br /> C­&'w <br /> c <br /> ACCOUNTING ONLY: AID/ FAC# <br /> 7N!FEEINTFOAMOVNTA TTED CHECKIICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> Pub.Health Serv.-Enviro.173(1/97) <br />