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f r)PPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> k <br /> P 0 80X388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 O� <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM GATE ISSUED <br /> (Complete in Triplicate) <br /> f <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 11 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC XZ� <br /> VICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APN# <br /> CITY OctQPARCEL SEZEIAPN# <br /> OWNER'S NAME ® - ADDRESS tvs �- mer j PHONE X 1 <br /> ���J/�j <br /> CONTRACTOR C ADDRESS u0#Z � <br /> .I J PHONE <br /> SU8 CONTRACTOR - <br /> .� ADDRESS LIC# . <br /> PHONE 0 <br /> TYPE OF WELIJPUMP: ❑ NEW WELL ' ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER i <br /> ❑ INSTALLATION :113 WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL t <br /> ©New Itl RepelrH.P. I�Z-.. J <br /> (TYPE Of PUMP] - DEPTH PUMP SET_FT. FIRST WATER LEVEL <br /> O <br /> ��❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING <br /> 8 <br /> ❑DESTRUCTION: 's <br /> INTENDED USE TYPE OF WELL CONSTRUCTION&PECIFCATIONS v <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM A <br /> t-LY/b0/ DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> MESTIClPFIIVATE - ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELIPVC <br /> ❑,PUBUC/MUNICIPAL ❑DRIVEN - DIA.OF WELL CASING % D U <br /> DEPTH OF GROUT SEAL SPECIFICATION R S <br /> ❑ IRRIGATIONlAG ❑OTHER GROUT SEAL INSTALLED BY {p <br /> 11 MONITORING GROUT BRAND NAME E- <br /> GROUT SEAL PUMPED: ❑Yee ❑Nn CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S <br /> APPROX.DEPTH <br /> LOCKING CHESTER BOXlSTOVE PIPE ' <br /> PROPOSED CONSTRUCTION/DRILLING METHOD MUD ROTARYS <br /> AIR ROTARY AUGER CABLE OTHER�� <br /> E HEREBY CERTIFY TH AVE PR AIRED TH$S'IAPPLICATION AND THAT THE WORK WILL Be DONE IN ACCORDANCJOAE WITH SAN JOAQUIN COUNTY bRDINANCE6,STATE LAWS,ANO RULES AND <br /> REGULATIONS OF E SqN AVE COUNTY. HOME OWNER LASED AGENT' IGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMI71 SSUEp,I SHALL NO ,EMPLOY R T WORKMAN' OMPETFSATI0 LAW6 OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLO FNS: "1 C IFY T T IN TH PE F E WORK WHICH THIS RM I6 fSSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN•&COMPENSATION LAWS OF <br /> CALIFOR A," THE CAN UST C 0 NCE FO REQUIRED 1 AT 120e1 OMPLE-TE DRAWING A WER AREA PROVIDED. <br /> Signed <br /> Tltls �� / II . <br /> Date iR <br /> ftPLOT PLAN(Draw to SmI Safe <br /> 1. NAMES OF STREETS OR ROADSINEAREST TO OR BOUNDING THE PROPERTY, !, <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION F SEWAGE DISPOSAL SYSTEMS, - <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, 6. N THE PR OF WELLS ADJOIN RADIUS PE ONE HUNDRED FIFTY FT.,. <br /> ON THE PROPERTY OR ADJOINING PROPERTY, <br /> .. <br /> - .... - .. s... .. <br /> .. <br /> - .. -. <br /> i <br /> Um <br /> t� <br /> 144 <br /> �.:,.� .. <br /> DEPARTMENT USE ONLY <br /> Apptloetion AGIBy 'I� . <br /> Date ea <br /> Ar _ [� ► � - <br /> i ^ <br /> Grout Inspection By D e Pump Inspection By 3+q1 L <br /> Data <br /> Destruction Inspection By <br /> Date <br /> Comments-. _ <br /> 77777 <br /> ACCOUNTING ONLY: Alps! q FAC# <br /> L <br /> " <br /> II <br /> �t <br /> PE CODES FEE INFO AMOUNT REMITTED !CASE{ RECEIVED BY DATE y^ PMWtT/SERVICE REOUE&t NUMBER II <br /> �� �� r INVOICE <br /> _qj gr <br /> D SS <br /> ;i <br />