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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 469.3420 <br /> 11011-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete IR TripIketel <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESS/OR APN/—_LLSF�—QS—,7� CIT-e_ Lot-)I PPAR''C,EL`SIZE/APN• <br /> OWNER'S NAME ��1�.1 ler ADDRESS —151 &V,�I Lit'ear ('•'�t 1I' . gQ44) PHONE I / 1 <br /> CONTRACTOR 5 ,,,L �1(y'�[�j[� L}'7J ADDRESS SkJrq(,,,� SiSLK�fIK.J UC 7.S/ i`NONEI4v'rj—s3Q <br /> BUB CONTRACTOR ADDRESS U UC/ PHONE 0 <br /> TYPE OF WELLIPVMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 1 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> (TYPE OF PVMPI C1N—❑Rev.lr H.P. DEPTH PUMP SET FT- FIRST WATER LEVEL O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPIYSICAL WELL I IJ BOIL BORINO S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPfCIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑ DOME9TIC"IVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEVPVC DIA.OF WELL CASINO D <br /> ❑ <br /> PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATIONTAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING [� GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea ON* S <br /> APPROX. DEPTH_( PST LOCKING CHESTER BOXi!;rnvE PIPE <br /> PROPOSED CONSTRVCTIONlDPoLLlNG METHOD: MUD ROTARY__AIR ROTARY AVGiR CABLt=_ OTHERQLYh3�S�JS� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT 1 HE WORK WALL BE DONE IN ACCORDANCE WITH ;aN JOAOU,ri COUNTY OMINANCEES,,`ST�A`T�E LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SONATURE CERTIFIES THE FOLLOVNN,:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS BVBJ O WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR'S HISINO OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PE�HOKR <br /> OF w WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE A ANT MUST CALL 24 AD N E FOR ALL REGISR j /TIONS AT 12061464-U23. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blpned X TIII. <br /> 1 D.t.— �_Q U—'Q <br /> PLOT PLAN ID­to 80.1.1 Beal. •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 /> J. 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 /> wee_ 0.- r ►tee --- <br /> DEPARTMENT USE ONLY <br /> APPIie.tlen Aeeeol /ed BY f 'C `" — Date t/ A­LI/ <br /> Grout I—Peellen BY ktkData P—P I—Poetlon BY Date <br /> c <br /> Deatnaalen Inaoeetl..BY <br /> / Data <br /> cen.mer,t.�o�'e-� o�C,� �-'�• 1,���yf �f (�U��1 b /��" . <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC�f rASH RECEIVED By DATE PEWIT/SERVICE REOUEST NUMBER INVOICE <br /> o I �pD 6��86 <br /> pub.Health Serv.-Enviro.173(3/96) <br />