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APPLICATION FOR WELLIPUMP PERMIT -*or <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201388 <br /> (209)4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tripileotel <br /> APPUCATKIN 16 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 8-1115.3 R D TME STANDARDS OF 6 J AQUIN COUNTY PU LIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR A I CRY r.L4n YAPARC SIZE/APNI <br /> OWNER'S NAME ADDRESS /1 ONE/ ,J <br /> CONTRACTOR ADORES �+K/ 11CI?�(n PHONE I � <br /> SUB CONTRACTOR r ADDRESS UC# PHONE# <br /> TYPE OF WELLIPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WLLL N ❑OTHER <br /> �/y 1L/� ❑INSTALLATION ❑WE iT'S]S(TJEM REPAIR ❑CROSS-CONN T REPAIR ❑VAPOR EXTRACTION ZEjL t J <br /> ❑Rep.lr H.P. 1 1(v�� DFPTH PIMP SETFT. FIRST WATER LEVEL 11`1_ O <br /> RYPE OF PUMP( --T <br /> ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL# ❑ 601E BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A U <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> AElDOMESTICT'RIVA7L GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING D <br /> ❑PUBLIC/MUNICIPAL 11DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME E ffLLVV��TT?)�� <br /> ❑MONITORING GROUT SEAL PUMPED:❑Yw ❑No CONCRETE PEDESTAL BY DRILLFR:❑Vs 13N. S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE 3 <br /> WOPOSED CONSTRlX:TIONIDRIWNG METHOD, MUD ROTARY AIR ROTARY AUGER CABLE OTHER <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 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$HALL NOT EMPLOY PERSONS SUBJECTTO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUB ONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORNIA.'THE//��PPUACAnMTyMMUU&STT�CCAAUL 24H'O�U�RS IN ADVANCE FOR ALL REQUIRED IN SPF TIONS AT 1 Del Ono 123.COMPLETE DRAWING AT LOWER AREAPRREO\DED. A <br /> 0f4 0 a4 <br /> SI.—I /1 J,l/11\ Tltl. Dn. / 1 <br /> PLOT FLAN ID—t.SCNsI Sul. 't. <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCAT OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OVTUNE OF THE PROPERTY,GIVING DIMENSION$AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6.LOCATION OF WELLS WHIN RADIUS OF ONE HUNDRED FIFTY <br /> ITFT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOI LNG PROPERTY. <br /> 1 I� _ <br /> r <br /> AUG 7155, <br /> Sn.N JrjHc�ulN uCUNT <br /> �N'JIF fT,M, ,"�MMITH DIVISION a 'I <br /> D.ea Ar.. 1 <br /> APPIIution Acopt.d BY /_/ Jy,� � JJ � I� ��� <br /> Groot Irw—i—BY <br /> D.ta Pump Irr—lPn BY. <br /> D. <br /> OsnuctlPn 1--,bn By <br /> CIMM <br /> ACCOUNTING ONLY: <br /> AID# FAC# <br /> PS CODES FEE INFO AMOUNT REMITTED CHEC MASH RECOVED BY DATE pERMITleO1VICE REQUEST NUN661 Ot-1.E <br /> U <br />