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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIhf <br /> ENYIRONMENTAL HEALTH 01YISION <br /> R,O, BOX M ' 04 EAST WEBER AVENUE:, STOCKTON, CA Vann 8$ <br /> (2091469-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Compbt&In Triplkoto) <br /> APPLICATION 18 HERE BY MADE TO THF SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TIPS APPLICATION IS MADE IN COMPLIANCE WRH SAN <br /> JOAQUIN COUNTY DEVELOPMENT fTlrrT E,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN <br /> ADD11E68 COUNTY <br /> N4TtYPUBLIC <br /> UBBLIC H.EAIQLT•tH/SER�V'I�.C,,ES,ENVIRONMENTAL HEALTH DIVISION.IVISION. <br /> VCITY IFUs—'CSJOBAODRE88lOR APN# 7p�Q��r� PARCEL BIZE/APNI <br /> OWNRS NAME 7OrQADDRESS jCY9 . <br /> .�0 <br /> CONTRACTOR Are/ V $ADDRESS6.0Alt. �7j I PHONE <br /> SUBCONTRACTOR <br /> LIC/ I�PHONE <br /> TYPE OF WE MP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL v ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> ❑ <br /> (TYPE OF PUMP) New 11Repelr H.P, DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ❑ OUT-Or-SERVICE WELL/ ❑ GEOPHYSICAL WELL# [E31 Anil BORING ,,J R <br /> I�DESTRUCTION• 109 jig-. "A4 �! ,Q, �Z�AJ .'� -0 Ll -i� i o/ L.JC[O`V <br /> Rl <br /> INTENDED USE TYPE OF WE CONSTRUCTION SPECIFI IONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVAT40N DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACKIBIZE TYPE Or CASING/STEEIJPVC DIA.OF WELL CASINO D <br /> ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPEO: ❑Yr ❑No <br /> CONCRETE PEDESTAL 8Y DRILLER:❑Yr []No 5 <br /> APPROX.OF"" LOCKING CHESTER BOXISTOVE PIPE S <br /> PROPOSED CONBTRUCTIONMAILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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 WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN*&COMPENSATION LAWS OE <br /> CAUFORMA.'ITAPPLICANT UST CALL 2i HOURS IN ADVANCE FOR ALL REOURED Ip&PECTIOr{/AT 12061R&&�2]. COMPLETE DRAWING AT LOWER AREA PRO DED. <br /> B10ned X Title , -n J[Jrtos, ' Dete I 3 (,' <br /> PLOT PLAN(Drew to Sahel Sella 'to <br /> 1. NAMES OF STREETS OR R0AD8 NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GRIM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTEMB. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED rIrTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> - - r <br /> DEPARTMENT USE ONLY <br /> Appllaetlen Accepted By Dole Aroo �. <br /> Groat MNpxtbn BY Date PUMP Intpeotlen By 1�1�T `] Date[[[ <br /> Deeln,otlon Intpeetkn By_ qp Data 1 <br /> CemmeMr. ���(}W�j.1� ( , �Jr' I V O•__,_.... <br /> ACCOUNTINO ONLY: AID# FAC# <br /> PE CODES FEE INTO AMOUNT REIMITTED CHECK#fCASH RECEIVED SY DATE PEI MITI&EAVICE REQUEST NUMBER INVOICE <br /> �— 0 s -ire— l <br /> Pub.Hearth Serv.-Enviro.173(3196) <br />