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APPLICATION FOR WELLIPUMP PERMIT _ <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388,304 EAST WEBER AVENUE,VOCKTON, CA 9MI388 <br /> 12091409-3420 <br /> NON-REF UNDABLE-PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplate In Triplkat6) <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCEWTT11 BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STAND�]A'R/p`8 OFAAN JOAQUIN COU PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADORES8IOR APNI [ CITY PARCEL SIZEIAPN# <br /> OWNER'S NAME ADDRESS PHONE A <br /> CONTRACTOR ADDRESS .� - I LIC PHONE/� <br /> SUB CONTRACTOR ADDRESS LIC• PHONE R <br /> TYPE OF ELLIPUMPEW ELL REPLACEMENT WELL ❑ MONITORING WELL I 13 OTHER <br /> NSTALLATION 13 WELL SYSTEM REPAIR ❑ CRO BS-CONNECT REPAIR ❑ VAPOR E%TRACTION WEIi I J N <br /> ©New❑ H.P.-3 DEPTH H.P._ DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (IVPE OF PUMP) _ <br /> li <br /> 11UT-OP•BERVICE WELL © OEO IYSICAL WELL/ ❑ SOIL BORNO R —31 <br /> EBTRUCTION: <br /> INTENDED USE TYPE CONSTRUCTION$PEGIFICATIONS ! A �J <br /> ❑ IND MAL L DPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> e�q <br /> l•L—•Yb/OMESTICIPRIVAT£ ❑GRAVEL PACKISIZ£ TYPE OF CASINOISTEELIPVCDIA.OF WELL CASINO �f <br /> ❑ PVBLICIMUNICIPAL 13DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R �- <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITOMNO GROUT SEAL PUMPEOt ❑Yee Ne CONCRETE PEDESTAL BY DRILLER:❑Yee CIN. S <br /> APPROX.DEPTH �. LOCKINO CHEMn BOX/STOVE PIPE g <br /> PROPOSED CONSTRUCTIONIDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE__-.- I� OTHER <br /> h <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER 09 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'a COMPENSATION LAWS OF CALIFORNIA.- CONTRAC7011'6 HIRING OR BU"ONTRACTING SIGNATURE CEITCIPIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE FE FMANCE OF THE WORK FOR WHICH THIS PERMR 18 IBBUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE UCANT MUST CALL 2 E IN RVANG€FOR ALL REQUIRED IN/S/P�jTIONS AT 12001464-M22. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed% Title_ _ <br /> Date '�✓� Ir <br /> PLOT PLAN ID aw.to 80091 Soda 'to <br /> 1. NAMESV",Z,OR ROADS NEAREST TO OR BOUNDING THE RTY. L. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSION$AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL 9YOTEM6. <br /> 3. DrMEN6tONE0 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT, <br /> 8TRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 1 ... .. _ - <br /> : <br />, - E;; N <br /> DEPAATMENT USE ONLY <br /> Applieatlon Aeeepted BY Date - Area <br /> Grout IMF-Milan BY bets Pump Impaction BY Dele v ✓ <br /> Deelnrcllen Impectlon By bete <br /> Cemmente; <br /> ACCOUNTING ONLY: AID# FACT <br /> coip <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK ASH RECEIVED BY DATE PERMITI6181TVICE REQUEST NUMBER INVOICE <br /> —19,0 -) L o 37D53 <br /> r S 03 7 DS-5 <br /> � Q D37D5 <br /> S <br /> Pub.Health SerY.-En Aro.173(3/96) <br /> ( <br />