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APPLICATION FOR WELLIPUMP PERMI <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOMON, CA 95201388 <br /> 1209) 466-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN# ry(j-/ K/E�i �,��yy(p 57— CITY PARCEL SIZE/APN# <br /> OWNER'S NAME ( JC'�Q L. (�R /t'l.< &1'-r,0z r� ADDRESS /f'��-3 ST,�f�? S,4T0_ 7�' PHONE,t 11(d,tl'l I <br /> CONTRACTOR`I S (J 'a2/e / i ADDRESS_�_D iSLtC�/i R,o✓/S:.y LICK T PHONE P]c+Y[zby_ 37S <br /> SUB CONTRACTOR ADDRESS LIC# PHONE# <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> (TYPE OF PUMP) <br /> 11 Now 11Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 0 ❑ SOIL BORING <br /> ❑DESTRUCTION: h <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 13 INDUSTRIAL �❑OPEN BOTTOM DIA.OF WELL EXCAVATION d DIA.OF CONDUCTOR CASING /V I� D <br /> L`7 <br /> ❑ DOMESTIC/PRIVATE GRAVEL PACK/SIZES SYd,jt) TYPE OF CASING/STEEL/PVC 2 r�}F/t_ 111nd / DIA.OF WELL CASING ,2 <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION_,Qt/HJ R <br /> ❑ I�RIGATION(AQ 11 OTHER GROUT SEAL INSTALLED BY AZ/t-(. ` GROUT BRAND NAME ? E <br /> MONRORlNG GROUT SEAL PUMPED: Yw ❑No CONCRETE PEDESTAL BY DRILLER: Yw ❑No S <br /> APPROX.DEPTH / LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTION/DRILLING METHOD; MUD ROTARY AIR ROTARY AUGER_ 1-" CABLE OTHER <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> r REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> } THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY T TIN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF <br /> CALIFORNIA.- THE PPU NT T C 2Tate <br /> IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1200)408-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> F <br /> Signed X L ' rt �. Tltie �� ?O N �• n/!S� Date <br /> PLOT PLAN(Draw to Scala)Sulu_"to� <br /> 1. NA/S OF STREETS OR ROADS NEA ST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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 /> f c' n1Lw.� �(o2i1i SiZie orsrc 7� <br /> .. :.. No4 <br /> .... <br /> PRIG <br /> .. .. Aa'RQJG. LT TN or <br /> E '- ' eAcgTlo�Saow4f <br /> ............ ..... .. <br /> O <br /> ;... . . ...;............,... <br /> ............ . <br /> ..... . <br /> tvtw <br /> b <br /> . <br /> .. . ..... ...........................`...... .. <br /> _ ............ ............ ... .................... ............. <br /> ... .. <br /> :. <br /> A <br /> N <br /> N. .. <br /> ... <br /> gam : teQ . <br /> .... ........ ...... ... .. awur�s:.�d<d <br /> Tia tC _ <br /> O 10 do ,.. .. <br /> ..... <br /> ... .:.. <br /> ........ .:.... <br /> ....................... <br /> i{IDTJ:......... ...:......: <br /> . <br /> s.0 Ec')Crbl�nN�dJ�7tsel -- . <br /> d Y;it4PQs �No.�1:.Atr. .... .... ....;....... . <br /> .. <br /> . .. <br /> . <br /> .........> <br /> �Iocicw.l.eAu�2 <br /> 5 . <br /> ..._...:.............. <br /> DEPARTMEASE ONLY 1 7 J� <br /> Application Accepted By Date / L/{% Ara <br /> Grout Inspection By Date Pump Inspection By Date <br /> i <br /> Destruction Inspection By <br /> Data <br /> i Comments: <br /> i <br /> t <br /> I <br /> 7 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES yFEE INFO AMOUNT REMITTED HEC RECEIVED SY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> C1 4 .�C) V C <br />