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APPLICATION FOR WELLIPUMP PERMIT <br /> `SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIb" <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOADUIN ST., STOCKTON, CA 96201-388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY <br /> /PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. '}'J <br /> JOB ADDRESS/09 <br /> APN# 2,36 7 /Z,79/kn �rl' ADDRESS PHONE// LL.�� PARCEL SIZEIAPNE� <br /> 43 <br /> CONTRACTOR //AA. I�Igf4 /�Je r ADDRESS /G LICY �Y6ZPHONE gjgrj <br /> SUBCONTRACTOR �/.� ADDRESS ��� LIC# PHONE# <br /> TYPE OF WELL./PUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑.�uCROSS-CONNECT///REPAIR [I VAPOR EXTRACTION WELL T_ ✓V ❑Naw O Ra,- HIP. DEPTH PUMP SmMFT. FIRST WATER LEVEL O <br /> (TYPE OF MMPI <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL R ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL El OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ,E DOINMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED By GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: 11Y. ❑NB CONCRETE PEDESTAL BY DRLLER:❑Y. [IN. 5L� � <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE AJC/ <br /> PROPOSED CONSTRUCTION/DIBWNG METHOD: MUD ROTARY AIR ROTARY AUGEfl CABLE OTHER rLP <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND PULES AN� <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIG <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES— <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAIJFDANIAA THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURc9�u\fyPE/CTIONS AT 120814!&342]. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Sic.#X 7N n A t Tltle '\ T DN4 <br /> PLAT PLAN ID, .y to Sahel S 1. •to <br /> 1. NAMES OF STREETS OR READS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PPDPOSED <br /> 2. OUTLINE OF THE MOPERK,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. 1 <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. !� <br /> u►�� o <br /> � <br /> �A nKi1 <br /> n5evl <br /> r' 4A1l19 �` <br /> T1 .. .- <br /> PIAP 6 19 " <br /> ... ... SAN .;OAQU I P,.r'C" <br /> PUP <br /> DEPARTMENT USE ONLY <br /> Applicetlpn AcceptM BY Dela Ara �L 4' <br /> Groot Impaction By Dete Pump Inepectlon By��..t <br /> -A� <br /> D.tructlon Impaction By Dob <br /> Commenb: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTEDEC /CASH RECEIVED BY DATE PERMITISEANCE REQUEST NUMBER INVOICE <br />