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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERI. _a <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br /> 1209) 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplets in Tripliestnl <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/Oft INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 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 ADDRESS/OR APNI 16 77 /- <br /> 17 Lowe,Ay RJ>. Ole' "SIfW910T)C ITV LOQ 7111-OP PARCEL SIZE/APNI ri /av'05 <br /> OWNER'S NAME ✓/• le, ADDRESS /b 777 AloklZ4mo ;CD. PHONE I <br /> CONTRACTOR 7eE-,97-e--A�'^S,pFC7'.e✓M FXPL OiILJ � ADDRESS a0 2 y 2-07 <br /> 9 (lzR .lp? I 98 <br /> 3-CB/!)l <br /> SUB CONTRACTOR JrojV _#VC ADDRESSo236S Wl¢W.9M zW, 1 p PHONE 'J6 S-?712- <br /> UCS <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> HYPE OF PUMP) 11New 11Repalr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> �g C� ❑,OUT-OF-SERVICE WELL 11 GEOPHYSICAL WELL I ❑ SOIL BORING <br /> Jc.3 g <br /> DESTRUCTION: / — S�GLC s/Jf/V,d A'2WCst/T �.Qo vT <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OFII CASINO/STEELJPVC DIA.OF WELL CASING D <br /> ❑ <br /> PUBLIC/MUNICIPAL 11 DRIVEN DEPTH 6F GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING /G / GROU T SEAL PUMPED: ❑Y— [IN. CONCRETE PEDESTAL BY DRILLER:❑Yee []No S <br /> ] <br /> APPROX.DEPTH r [0 LOCKING CHESTER BOXISTOVE PIPE g <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN 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 PERMITI UED,1 6H ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOL NO: CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMrT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFO IA.' THE PPLICANT MUS CA tH0 �INNCIE FOR ALL REQUIRED INS <br /> P <br /> EC <br /> TIO <br /> N <br /> SAT 120914441-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed X Title <br /> MOT PLAN(Drew to Scale)Scde 'to <br /> 1. NAMES OF STREETS OR ROADS NEA S O OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING ENSION6 AND NORTH DIRECTION. EXPAN61ON OF SEWAGE D16POSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WIT IHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> Lo��sE �9vC <br /> Pqt' 80-o5 <br /> Ll <br /> 1 DEPARTMENT USE ONLY I <br /> Appllcetlon Accepted By_M Dtle /1 Aree <br /> Grout Inspection By ----"LII Data Pump Inspection By Det. <br /> Doat—tion Inspectlon By Date <br /> Comments: \ - A- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT R TTED CHECK//CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />