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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN 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 Z YEAR FROM DATE ISSUED <br /> ICompNt*In Tr1pUe*t*I <br /> APPLtCA71ON 19 HERE SY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WDRK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOP/MEN�Tj�TrrLE,cyAPT 19-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDI ESS/OR APNf Il' ' <br /> A <br /> CRY �� PARCEL SIZEIAPN/ <br /> �� <br /> OWNER'S NAME I ADDRESS Y-+ /f ��� PHONE I !�_�__ J__Y✓4 <br /> CDNTRACTORveys-- � g <br /> ADDRESS l; C :LL� LACI -/UV' PHONE <br /> SUB CONTRACTOR C- �1/i ��.+ ADDRESS UCJPHONE 07 _ <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLf OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS"ONNECT REPAIR ❑ VAPOR EXTRACTION WELL f ,/ <br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p <br /> (TYPE OF RUMPI <br /> ❑ OU'T-OF-SERVICE WELL ❑ QEOPHYrICAL WELLS SOIL BOAINO g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION* A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION LI_ _ _ DIA.OF CONDUCTOR CASINO p <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK1817E TYPE OF CABINOISTF£IJPVC DPA,OF WELL CASINO T) <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION q <br /> 11IRROATIONIAG 13y>OTHER GROUT SEAL INSTALLED BY ✓L }Ip GROUT BRAND NAME - E <br /> q* NITOWNG GROUT SEAL PUMPED: ❑Y. [IN. C CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No S <br /> APPROX.DEPTH ` LOCKING CHESTER BOXMTOVE PIPE S <br /> PROPOSED CONSTRUCTIONIMLUNG METHOD: MUD ROTARY APR ROTARY AUGER CABLE O7HER y 4 <br /> I HMOY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUM COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERFtFIEB THE FOLLOVMNG:'t CERTIFY THAT IN THE PERPORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BIJ"ONTRACTING 8143NATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SNALL EMPLOY PERSONS SUBJECT TO WORKTWAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE APPLICANT MUST C/AJ� 4 HOUR/IN ADVANCE FOR ALL REOUIRED(IINNSPS�PECTION*AT I209I4ft-24". COMPLETE DRAWING AT LOWER AREA PROVIDED, <br /> Stoned X /.�.� •�' A�� _ Tlga "�� Dote O ~?—j6 I U <br /> PLOT PLAN(dew to Bcolol Bcola to <br /> 1. NAMES OF STREETS 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 OUTLUNEB AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RAM@ OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> t <br /> t <br /> . DEPARTMENT LOS£ONLY <br /> Application Accepted By,CO$t/�� lr /_nom. DH. v Ar" <br /> (I'avl Inspection BY Dau Pune Inspection By Data <br /> Oe inxtien Inspection BY Dote <br /> Cornme.NC <br /> ACCOUNTING ONLY: AID# FACE <br /> PE CODES TEE INFO AMOUNT REMITTED CHECKIICAIH RECEIVED BY DATE PERMITISIERNME REQUEST NUMBER INVOICE <br />