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APPLICATION FOR WELLIPUMP PERMIT <br />aAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br />1209) 466.3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in TTiplic$tel <br />APPLICATION 18 HERE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DE6CR18E0. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH CERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN/ TLS L7 11(- I)f^� v Ctril FOC [C`�p� <br />ADOREC8Nr <br />UPARCELSIZ <br />L'ct / 'EYYn7JNZ <br />`!ADDRESSh 7OWNER'S NAME �tPL��70NE N <br />'- 977— 77/3 <br />c Ly ADDRESS S3;w `3 <br />RUB CONTRACTOR4k L01-11/1.9 lj �i <br />sD <br />L—c7 <br />TYPE OF WELIJPUMP: <br />❑ NEW WELL <br />ONITORING WELL I��� <br />❑ REPLACEMENT WELLXm': <br />11 OTHER <br />FAC# <br />❑ INSTALLATION <br />11 WELL SYSTEM REPAIR R088 -CONNECT REPAIR <br />❑ VAPOR EXTRACTION WELL # <br />CASH RECEIVED By <br />DATE - <br />❑ New 11Repair <br />H.P. DEPTH PUMP SET FT. <br />FIRST WATER LEVEL <br />O <br />(TYPE OF PUMP( <br />9 <br />❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL I <br />❑ <br />SOIL SOMNO <br />R <br />❑ DESTRUCTION: <br />„r, <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />A�`` <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXCAVATION <br />DIA. OF CONDUCTOR CASINO,~{ <br />T <br />❑ DOMESTIC/PRIVATE❑GRAVEL <br />PACK/SIZE TYPE OF CASINO/STEEL/PVC <br />DIA. OF WELL CASING 2 r <br />O <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN <br />��/ <br />DEPTH OF GROUT SEAL TY <br />SPECIFICATION <br />R <br />RIGATION/AO <br />❑ OTHER <br />\\2 <br />GROUT SEAL INSTALLED B /J(`t -L-✓' <br />GROUT BRAND NAME <br />E <br />ONITORINO <br />GROUT SEAL PUMPED: Yea 11 me <br />CONCRETE PEDESTAL BY DRILLER: ❑ Yea [IN. <br />S �^^ <br />APPROX. DEPTH <br />J <br />/ <br />LOCKING CHESTER BOX/STOVE PIPE <br />S i• <br />PROPOSED CONSTRUCTION/DRILUNO METHOD: <br />MUD ROTARY AIR ROTARY AUGER 4-- CABLE OTHER <br />1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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 WOR( FOR WHICH <br />THIS PERMIT 16 ISSUED, 1 81{ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$ COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES <br />THEFOL G: ' CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PEn80N8 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFOR A.' 11E AlPPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPPEC/TTTON$ AT 12091409-2422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Bipned X Title- -- J l[[ a �J /O�: s Date -� <br />PLOT PIAN (Drew to So11s1 Coals ' to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOBEO <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- nu — m..eee.................... ......_­ <br />DEPARTMENT USE ONLY A <br />Appllcatlon Accepted By Data C. 0 y / 0 <br />!„[ J <br />- ^ Area_ <br />Grout Inspection BY ",,`—l�'Tyt�(/ Dale Pump Inspection By <br />Data <br />Dest,ts:tlen Impaction <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES FEE INFO <br />AMOUNT REMITTEDCIfE <br />CASH RECEIVED By <br />DATE - <br />U NUNBER INVOICE <br />9 <br />Pub. Health Serv. - Enviro. 173 (3/96) <br />