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APPLICATION FOR WELL(PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (109) 469.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Tripike(e) <br /> APPLICATION IS HERE B MAOE THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MAGE IN COMPLIANCE WRRI SAN <br /> JOAQUIN COUNTY DEVE� G' TITLE,CHAPTER 9.1 1 1 5.J AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR//A1TPN11 4,00 R�,V � yIG.� 1, `"L CITY_�1 PARCEL 912ElAr•FII <br /> OWNER'S NAME <br /> �L��CA�.,``L,j_,, OBIT ��(�yN,/µ'�i'f1 TCV1'N��ry,f`FLTV TN) ADDRESB �,�/,�t'"s R rj�' - I .� PHONE I�C�Q1�� <br /> CONT MCTOR—..�Cc," (J-W� �X1J111�Q�/y6� F'r ADDRESS Z3(eS K/Lsa(.C�jys S•5&�N uC/ /rlf t7l/f�I'HONE I may,• <br /> SVR CONTRACTOR ADDRESS UCI L.LSIc.=. PHONE <br /> TYPE OF WELL 1PVMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLS ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> R YPE OF PUMP) <br /> ❑New❑Ropelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> / O <br /> ❑ DVT-OF SERVICE WELL ❑ GEOPHYSICAL WELL/ lJ SOIL BORING T e <br /> ❑OESTRUCTIO N: <br /> INTENDED USE TYPE OF WELL CONE TRUC TION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING A <br /> D <br /> C^-1T DOMESTIC/PRIVATE ❑GRAVEL PACK1812E TYPE OF CASINO/STEELIPVC DIA.OF WELL CASING <br /> J PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION D <br /> R <br /> IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME <br /> f <br /> ?J MONITORING n GROUT SEAL PUMPED: ❑Uwe ❑Ne CONCRETE PEDESTAL SY DRILLER:❑Y• []No ,S <br /> APPROX.DEPTH /nc, LOCKING CHESTER BOX/s Tow,PIPE <br /> '"OPOSED CONGTAUCTION/ORILLING METHOD: MVD ROTARY AIR ROTARY AUGi:;I CASU: OTHER ikiS1� <br /> "EQERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> :IEGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF TILE WORK FOR WHICN <br /> '/IIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUS-CONTRACTING MNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN TME PERFORM A O TFIE WOR(FOR WHICH THIS PERMrT to ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.*RyLT-HE�Ap/PJUCANTT MUST CALL 24 I 1 ANCE FOR ALL REGUM NS►ECTIONG AT 12061 466-422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 810nwd X V Titlw �r�" <br /> v DeH <br /> PLOT PLAN IDrew to%W.1 Boole 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PIOPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNFS 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 /> tel. <br /> tF <br /> IL 4h <br /> Avviloellon Avveotod By. �T ��yq / Dete C O O Arwe C ^'(i U)A[}� <br /> Orale Irnvxllm By r "'✓ `�' Dele �� F1en0 Inrpeetlon By Dels <br /> 0—trttetlon Imvectlon By ,/ /�ONe <br /> Commerwe: - CJ q (� (/1/ /OL <br /> ACCOUNTING ONLY: AIDR FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC6ASH RECEIVED Sy DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> �! p 3 <br /> Pub.Health Serv.-Enviro.173(3/96) <br />