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APPLICATION FOR WELLIPUMP PERMIT <br /> *t-'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIZft. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 988,304 EAST WEBER AVENUE, STOCKTON, CA 9520,-388 <br /> (209) 466.3420 <br /> NDN•REFUNDABLE PERINIT EXPlAE3 1 HEAR FROM DATE ISSUED <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSpRUCTIAND/op INSTALL THE WORT(DESCRBED,THIS APPLICATION I6 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS of BAN JOAQUIN COUNTY pUeuC HEALTIi SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB AbDRE68/OR APNI J f r� ?(� (�'�/'I �Q�/ !/ .a.. �// <br /> !V,f�`AA PARC <br /> OWNER'S NAME 4C/W EL SIZEIAPN/ <br /> ADDRESS <br /> v <br /> CONTRACTOR_ ? , Y y� ""'""`E"q—'—_ <br /> ADDRESS! ,VF LICA(v Up l" <br /> SUB CONTRACTOR I j ADDRESS h <br /> UC06 d9OZZ7 PHONE I t l <br /> TYPE OF WELL/PUMP: ❑ NFW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ElINSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIA ❑ VAPOR EXTRACTION WELL <br /> ❑New❑ J <br /> Cdr H'P• DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> R YPE OF PUMP! � <br /> 11 DESTRUCTION: 13OUT I-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I2BO1I BORING 1 <br /> B <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION* <br /> ❑ INDUSTRIAL ❑OPEN BOTTOMT A <br /> DIA.OF WELL EXCAVATION - DIA.or CONDUCTOR CASINO p <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/91ZE TYPE OF CASING/STEEL/PVC DIA.OF WFLL CASINO <br /> 11 D <br /> PVBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SpECIFiCAmN H <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY_._�� c 1 P�' GROUT BRAND NAME <br /> MO ��ry-t�� � E <br /> NRORIN0 GROUT SEAL PUMPED: [I Yee E * CONCRETE PEDESTAL BY DRILLER:Spy []No <br /> No ,q <br /> APPROX.DEPTH, (// i/ •_ LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONfMtUNQ METHOD: MUD ROTARY AIR R (^OTARY AUGER CABLE OTHER `� b <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING on SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,R SHALL EMPLOY PERSONS BUBJECT TO WORKMAN'*COMPENSATION LAWS OF <br /> CALIFORNIA.' T"EA"CAIIT MUST CALL 24 HOURS IRAQVANCE FOR ALL REQUIRED INSPECTION*AT 12021490-34-22, COMPLETE DDRAWINO AT LOWER AREA PROVIDED. Q <br /> Stoned X (,�_�] TRI._ 50J �",T( ��^......Dole <br /> PLOT PLAN(Draw to%ole)Bade '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,QIV*M DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6, LOCATION OF WELLS WFTMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> OEPAIITMENT USE ONLY <br /> AppSeellen Aeeepled By Area <br /> Grow Irnpoetlon By Do-to Pump Inepeetlon By Dole <br /> Deetrtratlon Irxpeation By not. <br /> Cemmerda: <br /> ACCOUNTING ONLY; AID/ FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK/!CASH RECEIVED BY DATE PERNITI*ERVICE REQUEST NUMBER INVOICE <br /> AS 3 It �� <br /> Pub.Health Serv.-Enviro.173(3/96) <br />