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k,APPLICATION FOR WELLIPUMP PERMIT <br /> SAN,JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I. ENVIRONMENTAL HEALTH DIVISION <br /> P O,BOX 388, 446 N.SAN JOAaUIN ST.,STOCKTON,CA 96201.388 { <br /> (2091468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 0 Mompl$1$In TTIpDe$t$I <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE U/OR$C DESCRIBED.THIS APPLICATION 1B MADE IN COMPLIANCE WITH H SAN <br /> " JOADUIN COUNTY DEVELOPMENT TITLE,CHAFFER 9-1115.3 AND THE STANDARD&OF SAN JOAOUIN COVNTY PUBLIC HEALTH SERVIGEe,ENVIRONMENTAL HEALTH DIVISION, <br /> 91 1, a <br /> JOB AOORREBB/OR APNN = CITY Stockton PAncE-L azuAPNE 0_14 <br /> .� <br /> '� Y� Y <br /> OWNER'S NAME I.' ADDRESS 6 1 n _ Shi P1a Sh,•� PHONE 1213-777_AQ 87 1 <br /> CONTRACTOR John .L',rl Yllli n �'�R Acenr ADDRESS <br /> .�:rJ_t- - ._ taa._[Z 9..2,.72?i'TRONE.a 15-R�n-94 <br /> 1' �D `I z2 <br /> SUBCONTRACTOR qb.A sREBB LICONE• <br /> TYPE OF WEUJPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL# ❑OTHER <br /> Cl INSTALLATION ❑WELL SYSTEM PEPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL♦ ✓ <br /> CT N—0 R•O•1, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> STYPE OF PUMPI <br /> ❑OUT-OF-SERVICE.WELL ❑OEOPHYBICAL WELL R ❑ SOIL BORINQ g <br /> 661 DESTIMCTION: - <br /> INTENDED USE TYPE OF WELL p 4 C9 N$TIIUCTION SPECIFICATION& �r"� q <br /> ❑INDUSTRIAL ❑OPEN BOTTOM �� dA.OF WELt EXCAVATION Con A i-t n.hi g--VA.OF CONDUCTOR CASING D <br /> ❑DDMESTL[MIVATE ❑GRAVEL PACKISIZE TYPE OF CASINDJSTEELMVC CIA.OF WELL CASINO D <br /> ❑PUBUCIMVNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION R <br /> ❑ <br /> IRRIGATION/AG ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME E <br /> MONITORING I GROUT BEAL PUMPED:❑Ys ❑Ne CONCRETE PEDESTAL BY DRILLER!❑Yr 11 No 3 <br /> APPROX.DEPTH �', LOCKING CHESTER BOXJBTOVE RPE a, I <br /> PROPOSED CONSTRUCTIONMAILJJNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE'111Y CERTIFY THAT I HAVE PREPARED THIS AF'PLICA7ON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOADUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANp <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SVBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SU"ONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CEIUIFY THAT ISI THE PERFOfIMANCE OF THE WORK FOR WHICH TWO PERMIT IS ISSUED,I&HALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE WR ALL REQUIRED INSPECTIONS AT 170614864422.COMPLETE DRAWING AT LOWER AREA PROVIDED, <br /> {, <br /> &9—d K TTI• two 1 <br /> PLOT PLAN UN—to Becht s•w Rp <br /> 1,NAMES OF STREETS OR RDADB NEAREST TO OR BOUNDING THE PFWPERTY, 4. LOCATION OF HOUSE SEWAGE DISTOSAL SYSTEM OR PROPOSED I <br /> 2. OUTLINE OP THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. - EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3" DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED e. LOCATION OF WELLS WNIN RADIUS OF ONE HUNDRED FIFTY FT. I <br /> STRUCTURES,Irt <br /> NCLUDING COVERED AREAS BUCK AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, j <br /> ..:...... <br /> i. .. e <br /> $E "ATTACHED!"LOCATION MAP <br /> . - ....'-... <br /> .. -.,,. <br /> I DEPARTMENT USE ONLY <br /> 1 iL k <br /> Applle•Ilen Accented BY <br /> Orput Irrp•Gtlon by .I� ISI •-�..�^ <br /> D•1• P-0 Iwoctl#R SY <br /> Deel—ll#G IMpeetle�tl�BY (( 1 D•N <br /> Cammmte: SIL W 111 (,� G Data ,,_1 <br /> it <br /> ACCOUNTING ONLY: AID# li <br /> FAC# <br /> PE CODES FEE INFO AMOUNT RERLITTFDF� <br /> CHECIIs1CABN- RECEIVED BY GATE PERFAMSERVICE REQUEST NUMBER <br /> D �] INVOICE <br />