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APPLICATION FOR WELLIPUMP PERMIT _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 3BB, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201388 <br /> (209) 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CampIBM in Triplicatb) <br /> APPLICATION M HERE 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 /> MAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THEE A�NDAARDS OF SAN JOAQUIN COUNTYY PUBLIC H ALTH SERVICES.ENV)RONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN#i.2��y n J`Z /, 1/n r✓L&2 CITY ^ 1 PAR <br /> OWNER'S NAME.�E,� —ADDRESS <br /> ' <br /> CONTRACTOR NVI_!f / IA '1 , !L� ADDRESS c.� LICi32 �PHONFIy <br /> BUB CONTRACTOR ADDRESS LK# PHONE i <br /> TYPE OF WELVPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTAI-LATION ❑ WELL SYSTEM REPAIR 11CROSS-CONNECTREPAIR ❑ VAPOR EXTRACTION WELL# J <br /> 11NewNAaP.ir H.P. Z:k-- DEPTH PUMP SET . FIRST WATER LEVEL,/ �� O <br /> TYPE OF PUMPI N <br /> ❑ OUT-OF-SERVICEWELL ❑ GEOPHYSICAL WELL# ❑ SOILSORING S <br /> ❑DESTRUCTION' <br /> r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O 2 <br /> DOMESTICIPRIVATE ❑GRAVEL PACK]SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING O [ � <br /> El PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R �—iii/ <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING (% T GROUT SEAL PUMPED: ❑Y.. ON. CONCRETE PEDESTAL BY DRILLFR:❑Y. ON. S (}� <br /> APPROX.DEPTH��^� LOCKING CHESTER BOX/STOVE RPE S �t <br /> PROPOSED CONSTRUCTIONIDTBILNG METHOD: MUD ROTARY AIR ROTARY AUGEfl CABLE OTHER x <br /> 1 HERESY CERTIFY THAT I HAVE PMPARF.D THIS 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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOM FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMA CE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENBA N LAWS OF <br /> CAUFOIWMUST C M NO IM ADVANCE FOR ALL REQUIRED MLO IM ADVANCE FOR ALL INSP//�7NS AT( M)NBJQI. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 91'r, xTltl. Y� imb w/�— <br /> PLOT PLAN IDy.to Sc*.)SUM to <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 DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> G. 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 PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> I <br /> J <br /> le <br /> L <br /> r <br /> 1 <br /> GC� <br /> r 1 0.1 <br /> P- -- SEP 13 1995 <br /> >kIV,IUAuuII ,., <br /> DEPARTMEBT WE ONLY - ,fgi V� —7�L iRvi€:. <br /> APPIm .aan Accepted Br Dm w�/—/I Z. a..AL <br /> Grout IroPectlon BY Eat. Pump Nrosaon By��������� <br /> Dsvuoti.n I—Pclla,,By D.t. <br /> CammenH: <br /> ACCOUNTING ONLY: Alm FAC# <br /> PE CODES FEE INFO AMOUNT RIENI N ABH AWEIVED BY BATE PFRMITISERVICE REQUEST NUMBER INVOICE <br /> i'731 9/3 9J oaa973 <br />