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� APPLICATION .FOR WELLIPUMP PERMITL C' <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVWS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ti I 1 is=h(_ '0, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> "^= (209) 468.3420 <br /> ^•`t _n T;J ,,. NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complet6 In Tripliate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR DESCRIBED.THIS APPLICATION 16 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 ADDRESS/ JI CITY <br /> PARCEL SIZE/AFNI <br /> OWNER'S NAME � ) ADDRESS jl �& <br /> PHONE I <br /> CONTRACTOR '� C- ADDRESS <br /> LICi� �PHONE <br /> SUB CONTACTOR ----- ADDRESS <br /> LICI PHONE <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> �S �1�'T ❑ INSTALLATION ❑ WELL�gY)STEM REPAIR ❑ CROSS-CONNEFT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ❑New❑Repdr H.P. .-.! J <br /> VVVVIFFF`�E`E`E PPPP1IIIlIII �b�-� DEPTH PUMP SET FT. FIgBT WATEfl LEVEL0 <br /> R OF MPI <br /> ❑ <br /> El DESTRUCTION- OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING <br /> B <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> C❑ <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO W <br /> �VWMESTIC/PRIVATE El GRAVEL PACK/SIZE TYPE OF CASING/STEEVPVC <br /> / DIA.OF WELL CASINO D <br /> ❑ PUBLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑ IRRIGATION/AG ❑OTHER <br /> GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> El MONITORING E <br /> GROUT SEAL PUED <br /> MP : ❑Yw [IN. CONCRETE PEDESTAL BY DRILLER:❑Yw ❑No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRMTION/DI6WN0 METHOD: MUD ROTARY AIR ROTARY AUGER CABLE <br /> OTHEfl <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR WILL BE DONE IN ACCORDANCE WITH 84N 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 WHIG <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY FER60NS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIE <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.'/T�`4E PPUC/AINT/M�(U�ST CrL4 I1py�UR6/1N ADVANCE FOR ALL REOURED IN TIO/{N�S1 AT 1206/1/4/p/J 2]. COMPUFTE DMWINO AT LOWER AREA PigVIDED. <br /> Slpned X 1 .'l /lY ��/V//J��/ Title,,"� / Geta <br /> —/-(----PLOT—PLAN(D,.to Swbl Sole 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF MOUSE SEWAGE DISPOSAL BS. OR PgPO6EU <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION F SEWAGE DISPOSAL RADIUS OF ON. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. 6. LOCATION OF WELLS ADJON INGPRPE ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOINING PROPERTY, <br /> Iwo <br /> A <br /> PAYMENT <br /> ... <br /> RECEIVED <br /> APR 0 9 ISM <br /> SAN A),, 1UtN (J(JNTY <br /> PUBLIC HhALTII8MICES <br /> .._ .,, ENVIRONMENTAL HFALTIIIOIVISION <br /> T, S�. .. <br /> . <br /> l <br /> I <br /> DEPARTMENT USE ONLY <br /> GroutApplication Accepted BY <br /> Gram Impaction By D•re PampInePatlon By �a 2� <br /> Dwtructlen Impatlon BY <br /> U Data <br /> Data <br /> C.nnro b: <br /> ACCDUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED _CHECK CASH RECEIVED BY DATE <br /> PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> S 2-- q ��, �[ <br />