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APPLICATION FOR WELL)PUMP PERMIT <br /> SAN JOA13UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115 3 AND THE STANDARDS OF SAN JOAQUIN COU PU/B/1/}/C HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APNI /I TS (/ a c, CITY V(A - / J�/�/ PARC L SIZE/APNS <br /> OWNER'S NAME ADDRESS r • I f�" Z /PHONE IV <br /> CONTRACTOR L V" DRESS `C� /I c;s, PHONE N / L'I V <br /> SUBCONTRACTOR /v (� ADDRESS Ll�J// i LIC9SZL7 PHONE/S <br /> TYPE OF WELLJPUMP: NEW WELL py REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> a[/��-1,7q / ❑ INSTALLATION /❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> nYPEZ/w�`�V4' New❑Rep.lr H.P. 11!L DEPTH PUMP SETZ00,1FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> _ ❑ <br /> OUT-OF-SERVICE WELL // ❑ GEOPHYSICAL WELL R p ❑ SOIL BORING <br /> DESTRUCTION: / .5 % �dr��7` ��(/ �-��f� /— X'iX <br /> INTENDED USE TYPE OF WELL CO N6TRlX:TION SPECIFICATIONS /1 q <br /> El INDUSTRIAL �❑/OPEN BOTTOM DIA.OF WELL EXCAVATIO / Z L) DIA.OF CONDUCTOR CASING <br /> l]f DOMESTIC/PRIVATE pp GRAVEL PACK/SIZE TYPE OF CASING/STE C bye- l DIA.OF WELL CASING L" D <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL f r- SPECIFICATION / r7 <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY /S GROUT BRAND NAME E <br /> ElMONITORING GROUT SEAL PUMPED: Ye. '❑No CONCRETE PEDESTAL BY DRILL TROY- S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED C ONSTRUC TIO N/DW LUNO METHOD: MUD ROTARY_lAIR ROTARY AUGER CABLE OTHER <br /> 1 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SANJOAQUIN 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 WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-6 COMPEN6ATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURECERTIFIES <br /> THE FOLLOWING: I C IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF <br /> CALIFORNIA._ THE ANT MUS CA 2 HOURS IN ADVANCE FOR ALL REQUIRED INSPEC T 12/O/Y1�4Sa3/4/27�COMPL/ET/E/�it.AWING AT LOWER AREA PROVIDED. - <br /> lzSlaned X Tltle / D.cn G <br /> PLOT PLAN(Dr-to So.le)Scale_ <br /> 1. NAMES OF ST O ADS N /TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> _ 2. OUTLINE OF THE PROPERTY,GIVING MENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED <br /> N <br /> OUTLINES AD LOCA ION OF ALL EXISTING AND PROPOSED 6. 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 /> _ '. ..'r Tom. '►'Y1��-M c' _..:...(�`f _ <br /> g r r� �v ' <br /> Y u <br /> ...... ..... <br /> k <br /> 'x%ooc� s�'ro P <br /> Q T-oosed <br /> a. All. NT <br /> R�� F=leas` r; <br /> S �-b tNS-� �Q _ ` <br /> .� <br /> JUN 8.1995 <br /> DEPARTMENT USE ONLY C /1 �JVIRONIMENTAL MEAL-rH UIVISiON <br /> Application Accepted By \ 1.1�lTS \.'Z�y��c- - -_.__- - -- -__DSte- c, ! Z ' / \ Are. -) I-? - <br />