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`- APPLICATION FOR WELL)PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVR,..:S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WESER AVENUE,STOCKTON.CA 95201-388 <br /> (209)468.3420 <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 N COMPLIANCE WITH <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> ' JOB ADDRESB[OR APN/ �+ LG /� <br /> _ <br /> [.—JL_'Y.. G [ , --L,L[i t• _CR _ /Y y,/�_/.fes_- PARCEL SIZE/APNI <br /> � [[yy ��-. .PO;—2 <br /> — <br /> ADD NAME LG �Y27�'" ADDRESS�/G ,Zl — PHONE Z Y.I <br /> CONTRACTOR ADDRESS O/ - lLACI S LG/70PHONE <br /> �1`ir1:37)-S <br /> SUB CONTRACTOR_��� r.///[,s CX / � ADDRESS�I•Y��i4�2ti.✓f�/./�f..L-�AJCI !;e f/LS PHONEI <br /> —Z /7J 4YV.V.ra <br /> ' TYPE OF WEL1fPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL I ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELLe <br /> ❑N—❑Rp.1, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) �C ��) <br /> ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELLS- SOIL BOPoNO •[a-+ <br /> 11 DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRICTION SPECIFICATIONS- <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> ❑DOMEBTm/PWVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASINO <br /> ❑PUSUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑IRRIGATION/AG ❑OTHER !! GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> ❑MONITORING �" / /` GROUT SEAL PUMPED:❑Yee 11 N. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑N. <br /> APPROX.DEPTH ,/I i✓-�/F r <br /> LOCKING CHESTER BO%/STOVE PIPE <br /> PROPOSED CONS-i11UCTIONID10WN0 METHOD: MUD ROTARY AIR ROTARY_ <br /> AUGER CABLE OOT.D. <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 A <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WH <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIF <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S-COMPENSATION LAWS <br /> CALIFORNIA A►PUCy1nMLIST CA 24 HOURS-IN ADVANCE FOR ALL REGUMED IN9PECTIONS AT)2091�2a.C MPLETE DRAWING/AT LOWER AREA PROVIDED. <br /> slen.d x� i I r/!!//T// cyL TIT. /l��C S C: t 7� erJ f r_i t' D.t. //3l A,7 <br /> PLOT PUN(0—to Sed.)Sul. <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 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 /> DEPARTMENT USE ONLY ,�/ ,,///� { ,+ <br /> ApPlie.tlon Accepted By,- D.t.2.11 2,16" 2 A-1-0 <br /> Grout Impectlon BY D.te Pump In.peetlen BY �T D.ts <br /> D..truetlen Inp.ctlen BY D.t. <br /> C.mm.nt.:�ls•1.�1 Av( <br /> ACCOUNTING ONLY: AID/ FAC, <br /> PE CODES FEE INFO AMOUNT REMITTED HECK//CAbH RECEIVED By DATE PERMITMERVICE REQUEST NUMBER INVOICE <br /> d i c� f4(L l <br />