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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES •7°�' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> WON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICimpirti In TTIPliertr} <br /> APPLICATION IS HERE BY MADE TO 714E SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TiVA APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT <br /> TITLE./CHAPTER <br /> 9-1115.3 <br /> --1116.3 AND T E STANDARDS OF IAN JOAGUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADORESSMR APN/ I XQV / ///Cl.G I� !J�iJ _._. CITY G PARCEL S(ZFJAPHI <br /> OWNER'S NAME ADDRESS �FIONE � �'•' <br /> &�N cT[asi—� <br /> 9 <br /> CONTRACTOR ADDMSB� S• C��PHONE or <br /> bf <br /> SUB CONTRACTOR ADOMS8 LICE PHONE I <br /> TYPE OF WELLMUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I 13 OTHER <br /> TI-INSTALLATION'—D"W/ECL`SYSTEM]ITEPAIR' "- ❑'Cnous-CONNECT-REPAIR - ❑ VAPOR EXTRACTION WELL M- J <br /> ❑New❑Repe11 H.P. DEPTH RUMP SET FT. FIRST WATER LEVEL O I <br /> (TYPE OF PUMPI I <br /> CI OUT-or--SERVICE WELL ❑ GEOPHYSICAL WELL.P ❑ SOIL Boma 8 � <br /> ❑DESTRUCTION: I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONI A <br /> ❑ INWSTRIAL ,I❑�I OPEN BOTTOM DIA.OF WELt EXCAVATION CIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTIC/PRIVATE 0GRAVEL PACK/81ZE _ TYPE OF CASINO/STEE4/PVC�rr DIA.OF WELL CASING f�Z/A( O <br /> �0 <br /> 1 PUBUC1MUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL _ SPECIFICATION t7L/K•�� fl "' <br /> 1�1 IRRIiAtIONIAG. ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED:OM ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y. e S C <br /> APPROK.DEPTN LOCKING CHESTER BO%!STOVE RPE 5 <br /> PROPOSED CGNsrRUCTIDNlbRIWNG METHOD: MUD ROTARV�x- AIR ROTARY AUGER CABLE OTHER <br /> 4 RMNY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> IREGULAIIIONe OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWIN(It•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUD-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLO '1 CERTI THAT IN TI PERFORMANCE OF THE WORK FOR WHICH THIS PERMTT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIF C T MUST 24 HOURS IN ADVANCE FOR ALL REDU4RE0 INS Ni AT Tt2pt14N-f4 /� //COMPLETE <br /> Ib�M�W/1NG AT LOWER AREA PPgVID D. <br /> Signed X Title � �if/b./� r e4-14 f f/Lr/I_ ^Da!• <br /> PLOT PLAN(brow to Seelol Saab 'to <br /> 1. NAMES OF STREETS OR ROAOa NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PfloPOSEU <br /> t. OUTLINE OF THE PROPERTY,OMNO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DOOPOSAL SYSTEMS. <br /> 7. 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,PATIOB,D!wl. VAYB,AND VAS. _ ON THE PROPERTY OR AD omm PROPERTY. , <br /> - - - <br /> - : . = <br /> OL <br /> DEPMTMENT USE ONLY <br /> Application Aeoapted B DN• Hw�� <br /> O.aut Inrpeatbn BP Det `' PArrnp Impaction BY Dole <br /> Oaetntetlen I" 1 BY ,�/ y r•� bets <br /> Comment it) L. � h !d � 0 ��L{.� "1-C..►��j/ Q�CT �' <br /> ACCOUNTING ONLY: AID/ FACE <br /> PE Cob" FEE INTO AMOUNT REMITTED CHICKI ASN RECEIVED BY DATE PERIWTISPRVICE REQUEST NUMB@t INVOICE <br /> d saw �e fri <br /> PUb Health Serv.-Enviro.173(1/97) <br />