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APPLICATION FOR WELLIIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �] o P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 96201.388 <br /> (209) 468.3420 <br /> NON•REFUROARLE PEAWT EXPIRES I YEAR FROM GATE ISSUED <br /> i' <br /> pppLICATwN IS HERE <br /> fCompt to in Trip ate)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 E-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEFilACES,ENVIRONMENTAL HEALTH DIVISION. <br /> �/) r <br /> JOB ADDAESSlOR APN>t CITY s , <br /> PARCEL SIZEIAPNO <br /> OWNER'S NAME ' b nQ �6�r <br /> , - <br /> ADDRESS 12A00 r g .IPW y PHON ° 79-3 <br /> CONTRACTOR A 0 14 r 0a� /;It ADDRESS K d f+ 444 317-000 1 PHONE� � <br /> it ,. LIC*—.- l <br /> :SUBCONTRACTOR t - C ADDRESS 22,&S'L'o[WW i(A U., PHONE! <br /> T • <br /> TYPE oP WELIJPUMP: ❑ NEW WELL ❑ RULACEMENT WELL ❑ MONITORING WELL/ ❑OTHER <br /> ❑ INSTAL1ATtON ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR 13 VAPOR EXTRACTION WELL A' <br /> (TYPE OF PUMP] <br /> J <br /> 13 New C]ReP;r H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> - <br /> //13OUT-OF-$ ICE WELL ❑ GEOPHYSICAL WELL• I C1 SOIL,BORING <br />. OESTfiUC7lOM �Y' l` J�, t,4 W 1 fL+SSI.I,CC 9 <br /> INTp1DED USE TYPE OF WEyL CONSTRUCTION SPECIFICATIONS <br /> A <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 'DIA.OF CONDUCTOR CASING <br /> ❑ pOMESTIClpWO <br /> VATE ❑GRAVEL PACKlSIZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASINO _ <br /> D <br /> D PUBLICIMUNICIPAL ❑DRIVEN OEM OF GROUT SEAL SPECIFICATION <br /> -I R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT SRAND NAME <br /> E <br /> MONITORING GROUT SEAL PUMPED: ©Yr ❑Na CONCRETE PEDESTAL BY DFuuFR:❑Yw 13N. S _ <br /> APPROX.DEPTH LACKING CHESTER BOX/STOVE RPE <br /> PROPOSED CONBTRUCTFDNIDWWNO METHOD: MUO ROTARY MR ROTARY AUGER CABLE OTHER S <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOFIK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN 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 WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORIDMAN'S COMPENSATION LAWS-OF CAUFOANIA.' CONTRA.CTOR'S HIRING OR SUN•CONTRAC7ING SIGNATURE CERTIFIES <br /> THE WING: 'f CEFTI•IFY THAT!N THE PERFOFUAANCE OF THE 10 RK FOR WHICH THIS PERMIT 1$IBSUFJJ,I SHALL EMPLOY PERSONS SUBJECT TO WORIMAN•S COMPENSATION LAWS OF <br /> CALI RNIA.' T APPLICANT M 8T 124 (O 1 ADVANCE FOR ALL REQUIRED INSPECTIONS AT(MI 433,423. COM PLETE'.DMWING AT LAWER AREA PFOVI D. <br /> 90FAd X Thte 1�I R/Vl il. -.,e— <br /> ETS PSG <br /> PLOT PLAN(Drew To So"Saale 'to <br /> 1.,NAMES OF STRES OR ROADS N TO OR BOUNDING THE PRtOPEFiTY. - 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVI MENSMNS AND NORTH DIRECTION. EXPANSIONOP SEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS Of ONE HUNDRED FIFTY Fr. <br /> -STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> - .... ..... .... _ ...- <br /> i <br /> PEPARTMkM UGE ONLY <br /> APPlioetton Aeeepted By - <br /> Date � Alec L- O r <br /> Grout impecom By Date Pdmp tropeatien By <br /> pate <br /> Deatruetlen IngncNon BY Oete <br /> Commenb: <br /> :I <br /> AC COUNTING ONLY: AIWA FAC/ S . 02- <br /> PIE <br /> rQZPE CODES FEE INFO AMOUNT REMITTED CHECR>r/CASH RECEIVED BY DATE PEIMITI513TVICE REQUEST HUMERI INVOICE <br /> !I� <br />