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• APPLICATION FOR WELL►PUMP PERMIT <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES- <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 9M1,--aft <br /> (209) 466.3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -;:, ;;�.• ._ • :? ,u•• <br /> (Complete In Triplicate) <br /> APPLICATION 1S 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 <br /> /TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APNA' 'Y!�'.•7 �iJ .T_yj�j•I 1j� sT"— CITY �rp,.� <br /> - � 7� PARCEL SIZE/APNI <br /> OWNER'S NAME /', <br /> ADDRESS PHONE R <br /> '{ ••�•� <br /> CONTRACTOR V 5 [��e/X/LL/n�� AbDR / <br /> E6R ��I1//C•fd./Id UC1 PNONE/+T <br /> RUB CONTRACTOR ADDRESS , UC4 \ <br /> PHONE 1 <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑-,OOTHER �y <br /> ❑ <br /> INSTALLATION ❑ WELL SYSTEM REPAIR 11CROSS-CONNECT REPAIR Q7 VAPOR EXTRACTION WELL a <br /> RYPE OF PUMP) New 11RepairH.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLA' ❑❑ 801E BORING <br /> B DESTRUCTION: - - <br /> INTENDED USE TYPE OF WELL CONSTRUC StON SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_.jO ��CA/ DIA.OF CONDUCTOR CASINOA <br /> ❑ DOMESTIC"IVATE ElGRAVEL PACK/SIZE TYPE OF CASINGISTFEL/PVC 7 - 0 <br /> OIA.OF WELL CASING O <br /> ❑ PUBLIC/MUNICIPAL ,❑yD�RIVEN DEPTH OF GROUT SEAL 1L/SCJ— �cE,�- SPECIFICATION <br /> ❑ IRRIGATION/AO .!9 OTHER GROUT SEAL INSTALLED BY ySGdGC! r" E <br /> ��/ 4Y GROUT BRAND NAME <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑Ne CONCRETE PEDESTAL BY DRILLER:[�Ye. ❑Ne S C <br /> APPROX.DEPTLOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTION/DAILUNG METHOD: MUD ROTARY AIR ROTARY AUGER__CABLE OTHER 5 <br /> 1 HEREBY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND c1 <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 19 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CE FY THA IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PER SUBJECT TO WORKMAN'S COMPENeATI011 LAWS OF <br /> CALIFORNIA.' T C NT M T CALL 24 FIO URB IN ADVANCE FOR ALL REOUREO INSPECTIONS AT 120014693422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed X Title, <br /> Date <br /> PLOT PLAN ID,ew to Soalel SaNe�_`to <br /> 1. NAMES OF STREETS OR ROADS NEAREST 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 R. 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 /> . ..... :. <br /> cis <br /> :.. <br /> AGNAI-T ARTA; 'r . <br /> • <br /> T <br /> FD�oRlll�S ... ..., <br /> J"o"ek TAAftr( - .. .... <br /> :. . .;... : . .:. <br /> .. <br /> :U014SE: �blA1GDl�(,` 6 ZO Hp <br /> .....:. ...... ... <br /> ........:.... <br /> DEPARTMENT USE ONLY <br /> Application Accepted By h <br /> Dots Are. <br /> Grout Inepeetlen By Dete Pump anapeeticn By <br /> Date <br /> Oeatna:tlen Impaction By <br /> Date <br /> CommerHa: <br /> ACCOUNTING ONLY: AID# FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED HEC !CASH RECEIVED By DATE <br /> PERMIT/eEAVICE REQUEST Nl1M6Efl INVOICE <br /> Pub.Health Serv.-Enviro.173(3/96) <br />