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APPLICATION FOR INELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVWS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.,BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <br /> (Complete In Trlpliate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1111'15.3 AND THE STANDARDS OF SAN JOAQUIN COU'NNTTYY PUBLIC HEALTH SERVICE/S,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSMR APNI 2� �'Y� <]N1�.2�"r/�V-/ / <br /> CITY PARCEL n��.5}.'�7N TPARCEL SIZE/APNI <br /> OWNER'S NAME ��m P /K b, ADDRESS. (s�yloy�.{/,/J!Y(�/,� �} ///"!C' PHONE I <br /> CONTRACTOR ( ��✓iJ ADDRESS d%O �✓pg�fli y�// S LIC! IC✓�rJ�-3J PHONE I I�3tc -%/L 6 <br /> SUB CONTRACTOR <br /> ADDRESS / �.S�7f UCI <br /> PHONE! <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I 4 <br /> 11(TYPE OF PUMP) N.®Repelr H.P. DEPTH PUMP BET (LFT. FIRST WATER LEVEL_ OD` <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING S.( <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONe A <br /> ❑ INDUSTRIAL L1 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> ❑ DOMESTIC/PUVATE 13 GRAVEL PACK/SIZE TYPE OF CASINGISTEMVVC DIA.OF WELL CASING <br /> ❑ PUBUCR.IUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER w 1 GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING .y GROUT SEAL PUMPED: El Y. [IN. CONCRETEPEDESTALBYDWLLER:❑Yr []No S <br /> APPROX.DMH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTION/DRIMINQ METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> - <br /> I HEREBY 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 WOW(FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING BIGNATUIE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE <br /> AA/p}�l,1CANTy/MUST <br /> /CAM <br /> � 24 HOURS IN ADVANCE PON ALL REQUIRED INSPSCCTIONB AT 120/114441 128. COMPETE DRAWING AT LOWER AREA PROVIDED. <br /> m <br /> eiOdX �/!L /�„r'� Tltls Ll W 7"L/.P/ D.I. <br /> J/ PLOT PLAN IDrP.v to Sahel 6111. 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 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 /> t.L.L9S <br /> ` ... <br /> (' <br /> .... <br /> �. <br /> ... <br /> . OE3 .fig lr.S>t . <br /> &ZeL! .... <br /> . <br /> 061 .919 6 .... <br /> ..... �� it}iJ,ttJlAttOlnjR I <br /> .,. � :... . .. ..... <br /> RONMEN AL HEALTi4 ClV15l�n <br /> . <br /> f11s �7� r” . <br /> _ DF➢ARTMENT USE ONLY <br /> Applloetlon Acaeptati BY D.I. G, I Area <br /> Grout Impwtlon By Dtle Pt+mp Impectlon By � <br /> Dmtrmtlon Impaction By <br /> Det. <br /> Comments: <br /> ACCOUNTING ONLY; AID! FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED HEC II/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />