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APPLICATION FOR WELLIPUMP PERMIT <br /> S1, ,OAaUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201 388 <br /> 1209) 468 3420 <br /> MON REFUNDAKE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iComptate m Triprmtai <br /> PPLJCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />]AQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1y1115 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br />]B ADDRESSOR APNI 1 CITY PARCEL SIZEIAPN* <br /> ` ADDRESS PHONE I <br /> WNER$NAME <br /> ',ADOPIE86 IICI <br /> PHONE,#_ <br /> ONTRACTOR _ L{ � jj <br /> JB CONTRACTOR t J— <br /> ` ADDRESS Z C • LK;I PHONE I�LZ <br />(PE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL IDL MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELLI J <br /> ❑Naw❑Repair HP DEPTH RUMP SET FT FIRST WATER LEVEL Q <br /> YPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING 8 <br /> 3 DESTRUCTION , � <br /> A <br /> TENDED USE TYPE OF WELL CONSTRLNITION SPECIFICATIONS y J d <br /> [3 OPEN BOTTOM DLA OF WELL EXCAVATION DIA.OF CONDUCTOR CASING �+I� a <br />■ iNDUSTRIAL DIA.OF OF WELL CA <br /> Z.a O <br /> J DOMESTICIPRIVATE ❑GRAVEL PAgUSIZE TYPE OF CASING/STEEIOPVO ��jj (('- SING <br />] PUBl1ClMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL./ —L '"'T\ SPECIFICATION 9 <br /> ❑ <br /> GROUT SEAL INSTALLED By___, GROUT BRAND NAME E <br /> IRRIGATION/AG OTHER <br /> MONRORING GROUT SEAL PUMPED ❑Yr ❑Na CONCRETE PEDESTAL BY DRILLER.❑Yr 13 No S <br /> LOCKING CHESTER BOX/STOVE RPE S—C <br /> -PROX DEPTH r r <br /> 3oPoam <br /> LLINQ METHOD MUD ROTARY AIR ROTARY—AUGER. CABLE OTHER <br /> � <br /> +E ERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS AND RULES ANO <br /> G S 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 /> a IS ISSUED 1 SHALL NOT EMPLOY PERSONS SUBJECT Ll WORKMAN S CaMVENtATION LAWS OF CALIFORNIA- CONTRACTOR S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> IE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANC OF THE WORK FOR WHICH THIS PE <br /> RMTT 18 ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORIDMAN S COMPENSATION LAWS OF <br /> kUFORNIA' 7 L� MUS CALL 24''HO`UnS VANCE FOR ALL REGUIRED INSPECTIONS AT 1�}4*8-242] COMPLETE DRAWING AT LOWER AREA P"OVIDEyD �j <br /> y-' DFta G.. Lr� L • <br /> c�X / M1 nw "t <br /> PLOT PLAN{Drew to BcAs)Scuta 'to ]� <br /> 4 VOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED [V, <br /> NAMES OF STREETS OR ROAD$NEAREST TO OR BOUNDING THE PROPERTY EXPANSION Of SEWAGE DISPOSAL SYSTEMS <br /> OUTLINE OF THE PROPERTY GIVING DIMENSIONS AND NORTH DIRECTION S LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br /> DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED ON THE pROp��Y OR ADJOINING PROPERTY <br /> STRUCTURES,iNCLUOING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND �7 _ <br /> _ a <br /> DEPARTMENT USE ONLY ` <br /> Date Arae /�//'i <br /> oplkatIon Accepted BY <br /> out IrnpaoUen BY Oats Pump Irupactton BY Date <br /> Data <br /> rtructwn Irwoectlon SY .- l <br /> W <br /> omments <br /> ACCOUNTING ONLY AIOI FAGI <br /> FEE INFO AMOUNT REMITTED CHECK#/CASH RECBVID BY DATE POIMITtSERV10E REQUEST NUMBER INVOICE <br /> o � <br />