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APPLICATION FOR WELLIPUMP PERM)' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERII,_�S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WTTH SA; <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. C <br /> JOB ADDRESS <br /> /OR APN#_j�'`�yVQ� �- 1�Y tCt-rk•'c ( .��L-�wV\�CITYC� PARCEL SIZE/APN# ►SI�,SG'� J <br /> OWNER'S NAME �CSt. u>,J\ t \ I��7�ADDRES6II/^� . r, <br /> 1�I V N(37�'�V\ C-i•fE1 � t� PHONE/ 1-116L% <br /> '�l,�n <br /> CONTRACTOR r" �� C� ADDRESS-V7 '`c.. 5 LICK PHONE# 9��-C <br /> SUB CONTRACTOR !'--& n 4- <br /> E, Q a C,L� Tom' ADDRESS ,II c _ <br /> ��-Lt _ �� i��C , `�i.(M � UC:r PHONE Ir ^/tr 'J !. <br /> i <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL C <br /> (TYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# `L� ,SOIL BORING g <br /> ' ❑DESTRUCTION: /` <br /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION M DIA.OF CONDUCTOR CASINO U W' D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC IN{- DIA.OF WELL CASING D <br /> y ❑ PUBUClMUNICIPAL ❑DRIVEN t DEPTH OF GROUT SEAL <br /> T SPECIFICATION R <br /> G <br /> ❑ IRRIGATION/AG OTHER JC' — GROUT SEAL INSTALLED BY GROUT BRAND NAME 1CX IO E <br /> MONITORING ` (� GROUT SEAL PUMPED: *. ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee [IN. S <br /> tI <br /> APPROX.DEPTH OAU LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONIMULING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANC <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 WHICF <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 CERTIFIEE <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE rERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of <br /> CALIFORNIA.' TM ATILICANT ST CALL 194 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 1209)44893423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed X Title `E�t-C'j;u� Dote <br /> PLOT PLAN(Drow to Scale)Scale 'to <br /> 1. NAMES OF ST ETS 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 OUTUNFS 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 /> '� 11, <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By A-.4�7KQ- \ Arm E<-lty, IL91CD <br /> Grout Impaction By Dote O Pump Inspection By Date <br /> Deetructlon Irnpectlon By ,.)' / Dote <br /> c <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEQ1QCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />