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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (COF"F1114 IR TF%11*1HI <br /> APMWA\'ION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCR11BED-THIS APPLICATION SS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,/'CH^PIER 9-1116.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVIStON, <br /> JOB ADDPIESSlOR APNI__ �[/ 4 j-)., CITY - - I G y PARCEL SIZEIAPN/` <br /> OWNER'S NAMEc "C ADO"F$R PHONE <br /> LA J11 <br /> CONTRACTOR1" -1 L ADDRESS <br /> FUS CONTRACTORADOFIESBF-� LICA ~~ PHONE t �T <br /> TYPE OF WELUPUMP; ❑ F+-11V WELL ❑ REP4ACEMEHT WELL ❑ MONITORING WELL f ❑ OTHER <br /> ❑ INSFALLATIOR ❑ WELL S)�F! EM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL E J <br /> 13New❑Repdr N-R` DEPTH"UMP MRT- FIRST WATER LEV<-L <br /> PE p <br /> {TYOP PL1MP1 e <br /> R m �� ❑ OUT-OF-Sf;RVLCE WELL ❑ OEOPFIYSICAL WELL• ❑ BOIL SOMNU S <br /> ❑bES1RUCTION• <br /> INTENDED UiE TYPE OF WELL CON%TRUCTION SPECLFICATION4 A <br /> ❑ rNI) FOAL L.J OPEN BOTTO" OIA.OF IMFLL EXCAVATLON DIA.OF COMOUCTOR CASING p `Y <br /> Il„�lF'f 1F9TICR'FIVATE "❑y GRAVEL PACRISRE TYPE OF CAFLNQI9TEEL1Pvc DIA,OF WELL CASINO p <br /> ❑ PUBUCIMUNICPPAL U DRIVEN DEATH OE GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E _ - <br /> ❑ MONITORING GROUT SEAL T1IMPED: ❑Ye. Elmo CONCRETE PEDESTAL SY DRILLER:❑Yel [IN. S <br /> APPROX.OFP7H LOCKING CHESTER ROXfFTTOVE PIPE <br /> 5 <br /> PROPOSERS CONSTRUCTION/DRILUNO METHOO. MUO ROTAIN!_ - AIR 710TARY AUGER CABLE OTHER I_ <br /> I HF4EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL SE GONE IN ACLORDANCE VATH SAN JOAOUIN COUNTY ORDINANCEB,STATE LAWS,AND RULES AND <br /> REGIAATIDNB OF THE SAN JOAOUfN COUNTY, HOME OWNER OR LPCFNSED AGENT'S SIGNATURE CERTIFIES THE F-OLLOL'YINQ;'I CERTIFY THAT IN THE PERFORMANCE of 111E WORK FOR WHICH >> <br /> THIS PFRMIT IS ISSUED,1 SHALL HOT INIPLOY PERSONS SUBJECT TO WOMIRMAN'1 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTWO SIONATUPF CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE 1NI-W fan WHICH THIS PERI.R'T 10 ISSUED,1 SHALL EMPLOY PERFONS SUBJECT TO WORIOIRAWS COMPtNIATION LAWS OF <br /> CALIFORNIA.' Tffl APPLICANT MUST CALL 24 HOURS IN ADVANCE FOA ALL REQUIRED IN PFCTIONS AT(20414"-5422, C//OMPME DRAYr1NG AT LOWER AREA P"13IRDED. <br /> Slaved X 4 Th1rDN. /d — .=✓ - <br /> PLOT PLAN INaw to Seale,Se.le "le_ .. <br /> 1. NAMER OF STRFE78 OR ROADS NEAREST TO OR BOUNDING THE P%DFF PTY_ 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 7. OUTLINE OF THE PROPERTY,GIVING DIMENBPONS AND NORTH DIRECTION. EXI'AHQION Or SEWAGE DISPOSAL SYSTEMS. <br /> 3. DMAENAtONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELL4 W1TH1N RADIUS OE ONE HUNDRED TIFTY F7. <br /> STRUCTURES,INCLUDING COVERED^PEAS BUCH AS PATI011,OR IVEWAYS,AND WAtXR. ON THE PROPERTY OR APJOININO PROPERTY. <br /> n <br /> t � ST-S]iti <br /> II <br /> 1 t <br /> DEPARTMENT USE ONLY 1 <br /> ApolceHen Ac.,Vted By_ bele ! ■Ar.a <br /> (herr[Ire Pee Non BT Oae�PUmP In.pe Oen By _ Y--� "Oblee""",��"��----TT�p' -- <br /> 1f-atr..:Nen ln.nee llm By^ Dale <br /> ACCOUNTING OILY; AID/ FACT <br /> PE CObEf FEE INFO AMOVNT REMITTED HEC !CASH RECEIVED by DATE P9W T11ERVICE REQUEST NUMBER INVoICz. <br /> 4' 6 0593 <br /> NIS � 1 <br /> Pub.Health Serv.-Enviro. 173(1 W) <br /> I <br />