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iPPLICATION FOR WELLJPUMP PERM" <br />SAi JAQUIN COUNTY PUBLIC HEALTH SES, - ICES <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 in Triplieste) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br />JOAQUIN �JCOUNTY �VELOPMENT TITLE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB AD OR APN# YP yjq2AC�) <br />CITY� PARCEL <br />9eIrZf�E/AFJI <br />OWNER '8 NAME ADDRESS 2� <br />_X1c/1/, / _JA <br />CONTRACTOR <br />ADDRESS�C/ & G 2 PHONE # A <br />run CONTRACTOR ADDRESS_ �� UC# PHONE # <br />TYPE OF WELL/PUMP: <br />❑ NEW WELL <br />❑ REPLACEMENT WELL ❑ MONITORING WELL # <br />❑ OTHER <br />FAC# <br />❑ INSTALLATION <br />❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR <br />❑ VAPOR EXTRACTION WELL # <br />CHECK#/CASH <br />RECEIVED BY <br />❑ New ❑ Repelr <br />H.P. DEPTH PUMP SET FT. <br />FIRST WATER LEVEL <br />Cr`j ``}} <br />O%_/ <br />HVPF <br />❑ OUT -OF -SERVICE W�'FLL ❑ GEOPHYSICAL WELL A <br />[- S <br />Lh 601E BORING <br />((� <br />g <br />T UCTIOPUMPI <br />❑ DfSTRVC710 N: <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />A 1 <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXCAVATION 2 ,( <br />DIA. OF CONDUCTOR CASINO A4 <br />A <br />❑ DOMESTIC/PRIVATE <br />❑ GRAVEL PACK/SIZE <br />TYPE OF CASINO/STEEL/PVC <br />DIA. OF WELL CASINO <br />O <br />❑ PURLICIMUNICIPAL <br />❑ DRIVEN <br />DEPTH OF GROUT SEAL �n _ SPECIFICATION q <br />�❑ RRIGATIONIAG ❑ OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME20tE <br />lr�� <br />IJ <br />MONITORING I GROUT SEAL PUMPED: ❑ Yee [IN. CONCRETE PEDESTAL SY DRILLER: 11Y- ❑No 5� <br />APPROX. DEPTH_ LOCKING CHESTER BOX/STOVE PIPE S ) <br />� <br />PROPOSED CONSTRUCTIONIDiW <br />tlNO METHCOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER ,V <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, ANO RULES AND ' <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 WHICH <br />THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUR CONTRACTING SIGNATURE. CERTIFIES <br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' T CANT MUST C S IN ADVANCE FOR ALL REQUIRED( IN�NSS7P/ECCTTIOON@ AT 12001460-1423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slpned k Title__ <br />PLOT PLAN (Drew to Soelel BoNe ' to <br />1. NAMES OF RTREFTS 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 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 />: E..^AFTMENT USE ONLY <br />APDlleetlen Aoeepterl By � V ` �/l/1/ /�� _ bMs Arse <br />Grout IMPeollon BY nn Cy bete 3 Pump Irnp-tlon By Dete <br />Ornlnrctlen Irnpeellen <br />Cornmft,w <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK#/CASH <br />RECEIVED BY <br />DATE – "P61A111T/SEAVICE REQUEST.NUMBETI <br />INVOICE <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />