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k; APPLICATION FOR WELLIPUMP PERMIT D Q s <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 988, 904 EAST WEBER AVENUE, STOCKTON. CA 9%01-BB <br /> 1209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRON DATE ISSUED <br /> ICnRplen In Triplimtel <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRHIEO.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVE810N. <br /> JOB ADDRESSlOR APNf 4is _ -1CITY r rft � PARCEL SIZEIAPNf <br /> Te-d7-a. />� <br /> OWNER'S NAME_ AbbRESS PHONE f�,.,,F�`�& <br /> PrZ ?t'. t ,�f LIC PHONE I' C.L� cJt T <br /> CONTRACTOR ADDRESS <br /> `^ -- <br /> BUB CONTRACTOR ADDRESS LIC# PHONE■ <br /> TYPE OF WELLIPUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONTrORINO WELL# ❑ OTHER <br /> �❑7 INSTALLATION ❑ WELL EM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTAACTION WELL J <br /> yp <br /> Now❑Repair H.P- DEPTH PUMP SE4kOFT. FIRST WATER LEVEL_ <br /> RYPE OF PUMP! /� � <br /> ❑.OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL PORING <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS VV <br /> 13INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION MA.OF CONDUCTOR CASING <br /> OOMEBTIC/PRIVATE ❑GRAVEL PACK?SIZE_ TYPE OF CABINOISTEEL/PVC -_piv, <br /> DIA.OF WELL CASINGS Al <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEALf twt � r _ SPECIFICATION /1 C P A <br /> ❑ IRRIGATiON/AG ❑OTHER GROUT SEAL INSTALLED BY - _ GROUT BRAND NAME £ <br /> ❑ MONITORING p GROUT SEAL PUMPED.-,Z Yr ❑Np CONCRETE PEDESTAL BY DRILLER:Q Yr ❑No <br /> APPROX.DEPTH �! :� LOCKING CHEWIER BOXIVTOVE PIPE_ <br /> PROPOSED CONETRUCTIONIDWWNG METHOD: MUD ROTARY, if AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND I HAT THE WORK WILL 91 DONE IN ACCORDANCc WITH BAN JOAQUIN COUNTY ORDINANCES,WrATE LAWS,AND RULES <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWW OF CALIFORNIA.' CONTRACTOR'S HIRING DR SUB-CONTRACTING SIGNATURE CE <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE-OF THE WOW FOR WHICH THIS PERMIT TO ISSUED,-I-SHALL EMPLOY PERSONS SUBJECTTO WORIGNAN'S COMPENSATION LAWN . <br /> CALIFORNIA.' THE PPL! ANT MUST C LL Z4 NOURe IN ADVANCE FOR ALL BEGIN ED TNG TKINS AT 12CVOI 4811-31211, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> t <br /> Slarxd X bJ/` <br /> 'l. Tltla I Data <br /> PLOT PLAN[Draw to Sara)Scala '.a <br /> 1, NAME19 OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. i. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> -� 2. OUTLINE OF THE PROPERTY,OMMG 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 /> � � l <br /> IL <br /> DEPARTMENT USE ONLY <br /> Applleallen Accepted BY_ i Date _A,. ♦�Z� �y� <br /> Growl Irnpeatlon ByT j � Gate 2 Pump Inapmtlen By <br /> DmIrmllon Impeatlrfnn By Data r <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED C #!CASH RECEIVED BY DATE PERM INVOICE <br /> L/3 r 9 DSD�(ocf <br /> 040705 <br />