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1 <br /> �. �"'�'IPPLICATION FOR WELLIPUMP PERMIT <br /> 3A4..,OAIIUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 386,304 EAST WEBER AVENUE, STOCKMN, CA 95201 86,: <br /> (209) 460-3420 <br /> 0j EFUNGA8LE PERIIEIT EXPIRES 1 YEAR FROM HATE ISSUED <br /> (((�llll <br /> (Complete in TrlpUesrlr) <br /> A CATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOOn INSTALL THE WORK DEBCRIBFD.THIS AP`P'LICATION IS MADE IN COMPLIANCE WDTN SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PURLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APN# 2 D 7 — /A -0% _ ---CITY e.5 PARCEL SIZE/APN# �^f ���'6/ � 4••� <br /> /` # S 3/7 <br /> OWNER'S NAME C Dr S C ile PHONE ADDRESS / �•- <br /> CONTRACTOR ADDRESS I� �J � ..L1Cr O� PHONE r <br /> RUB CONTRACTOR - ADDRESS LIC# PHONE r I <br /> 1 I <br /> PE OF WELUPUMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITOPtiNG WELL r ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> } <br /> ❑New❑RoVaIr H.P. DEPTH PVMP SET FT. FIRST WATER LEVEL D . <br /> ITYPE OF PUMP! <br /> © OUT-OF-BIR F. Ll ❑ OEOF'41YS1GAl WELL I © BOIL BORING <br /> DESTRUCTION-- <br /> r � + <br /> INTENDED USE YPE OF W CONSTRUCTION SPECIFICATIONS A <br />❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D !p 31 <br /> D <br />❑ bOMESTICrPRIVATE ©GRAVEL PACK/SIZE TYPE OF CASINGf8TEE1JPVC DIA.OF WELL CASINO I <br /> PUBLICIMUNICIPAL ❑ VEN - DEPTH OF GROUT SEAL SPECIFICATION R <br />(3DRI <br />❑ IRRIGATIONlAG ❑OTHER GROUT SEAL INSTALLED BY - GROUT BRAND NAME E <br /> ❑ MONITORING GROUT REAL PUMPED; ❑Yb. ❑Na CONCRETE PEDESTAL RY DIMLLER:❑Y.. ON. S i I <br /> APPROX.DEPTH LOCKING CHESTER BO%!STOVE PIPE <br /> PROPOSED CONSTRUCTIONMRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER f <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED T0119 APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR tICENBED AWNT'8 SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT TS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'@ HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES ' <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOISC FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATE N LAWS OF r J` <br /> CAtIFORNIA." THE ANT UST CA HOURS IN ADVANCE FOR ALL REQUIRED INSPECTS HS AT 12W 4AS1*422. COMPLETE ORAWINO AT LOWER AREA <br /> PROVIDED <br /> ��� e OHe s <br /> eltlr+ed%^ y��7e A Title <br /> PLOT PLAN{Drew to Scele)Serle <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 b1ItECT16N. ` <br /> EXPANSION OF SEWAGE DISPOSAL SYSTEMS. "I <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S, LOCATION OF WELL@ WITHIN RAMUB OF ONE HUNDRED FIFTY FT. } I <br /> STRUCTURES,INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROFERTY OR ADJOINING PROPERTY. <br /> Ilk4 r <br /> r4 1 qy <br /> nom: <br /> : <br /> : <br /> . .. 5 <br /> .. I <br /> , <br /> - , S <br /> . '. ... .. . .. .. .. .. �: ::. .:;yr <br /> :. <br /> ..., - ` <br /> ONiY'— <br /> .:..- <br /> AppllaMlen Accented By Y ` '" - Detb Ar��. <br /> Grout Inrpeelien By note tea/ FVm3P lmpectlpn Sy Dele i <br /> Al <br /> Derduellen Inspect fon If Li �`' r�I'N'^ +DO H <br /> comment.: <br /> ACCOUNTING ONLY: AID# FACS <br /> 1` PE CODES FEE INFO AMOUNT REMIT CHECKS ABH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER- INVOICE - y <br />