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APPLICATION FOR WELLIPUMP PERMIT <br /> sAN JOAQUIN COUNTY PUBLIC HEALTH SER►.- <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I 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(G <br /> JOB ADDRESS/OR APN#L//3/iy OfYEYS F� ,Qlenv/SEA CITY Oy <br /> Lff7hWi)O PARCEL SIZE/APN# <br /> OWNER'S NAME L/&BY ///N 5W 'O,efp ADDRESS .SOD "''//QC/,x4 5yd • PHONE# <br /> CONTRACTOR T,2C-'�grE,C—�,2.►7 ADDRESS?D2 Y�L LZ�2/�/i1/ ✓°CZ✓r LIC# PHONE I yd3-6 8!D <br /> p7 <br /> SUB CONTRACTOR S/-1Er T,ev/�/ �",Y,�[Q,e/�T/Q/l/ ADDRESS�36 S WI&L ,4W Oe. uc# S/2 2(,J vPHONE 9'165_0/1 2 <br /> TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> (TYPE OF PUMP) C1New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> �j s� ❑.OUT-OF-SERVICE WELL / ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g <br /> DESTRUCTION: / � (� Si�II/��CC�/E�/l �20�T TjQ�/'t•//(�' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION• A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/S_TEEL/PVC DIA.OF WELL CASING D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION g <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DRIVER:❑Yee []No S <br /> APPROX.DEPTH /50 LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONIDRILUNO METHOD: MILD ROTARY AIR ROTARY AUGER CARIE OTHER <br /> I HEREBY CERTIFY THAT I 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERM ED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE F OWING: CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPF?ISATION LAWS OF <br /> CALIF NIA.' THE CANT MUST CALL 24 HOUR AD ANCE FOR ALL REQUIRED INSPECTTIIIONN&AT 1209)469342]. COMPLETE DRAWING AT LOWER AREA PROVIDED. 9 <br /> Slprxd X Title �'/ Due 5— /� <br /> PLOT PLAN(Drew to Scale)Scale 'to <br /> 1. NAMES OF 81 RESTS OR ROADS NEARS O OR BOUNDING T14E 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 8. 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 /> g�v V/ pyo. <br /> �j ... <br /> i20 o .. <br /> ...... i, <br /> D,., �� DEPARTMENT USE ONLY L� Q <br /> Application Accepted BY rr..�VV t—"""—�� Dele ` ) t l Area <br /> Grout Inspection By `. Date Pump Inspection By / Due <br /> Destruction Inepectlon By _ 'I Date - 1 I A <br /> \\ �T��� �� v <br /> Comnt <br /> mes: 20 Y"RLfI/ A ' ty �a, <br /> V 1cq� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH IIECOVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> �� IA I IS✓ <br />