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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, SO4 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 468-3420 <br /> NON REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (CoAPPLICATION IS HEREBY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT I <br /> TRUCTAND/on INSTALL THE WOW DESCRIBED.THIS APPLICATION IF MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.C14AA2PTEER 9-1115.3 AND T14E FTANDARDR OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNI `j� ^©�,J / -� CIT! W D( PARCEL SIZE/APNI t <br /> /w, �-_ ` G <br /> OWNER'S NAME �( � T /� _p �,� � t� FAQ <br /> -` F1 Qr ADDRESS GNI:ISI rte:YCL4 1LA� Sm It' ✓t,f\I'7(+.KLSC:�!h4ONEIr L{I5-ZI —21L-13 <br /> - <br /> O6PMtOti6ig/f C:14 :PPS:Lei•,�'71�i 1 l �7 <br /> _ ��jj ADDRESS �L':.-Vl' e ' CI 11c-1 LIC, NDN PHONE Ic�b^� {'-'%J�[�j <br /> SUBCONTRACTOR �t1�i`17�F1A° L-�CP. VI.�LL..�(V I�i P' 1 nc��i4-7 <br /> ADDRE68 ( �, //''qq q.Z — CII <br /> / i CA LICt PHONE/ (c'5`11 - <br /> Y5iL 4i <br /> TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMFIIT WELL ❑ MONITORING WELL♦ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> El J <br /> N—❑P-1, H.P. DEPTH PUMP SET FT. <br /> (TYPE OF PUMP! FIRST WATER LEVELEl DESTRUCTION: �� O <br /> ❑ OUT-Or-SERVICE WFLL ❑ GEOPHYSICAL WELL I K SOIL BORING S•_20� I N Ler + <br /> R <br /> INTENDED VSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> EJ INDUSTRIAL — Q •• A <br /> El BOTTOM DIA.OF WELL EXCAVATION t` <br /> DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/RIZE TYPE OF CASING/STFELR'VC <br /> /n� DIA.OF WELL CASINO D <br /> ❑ PuStICIRR,rA IO NICIPAL El DRIVEN DEPTH OF GROUT SEAL Fu-L-4- V-eP ?[{ SPECIFICATION <br /> ��QQ F <br /> ❑ IRRIGATION/AG lO.OTHER -�'�'� <br /> lJf✓`.�'k,u r'LrTk7�+7 1C .,;,-GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> E <br /> MONITORING GROUT SEAL PUMPED: [IY.. [IN. <br /> APPRO X.DEPTH ✓� 1� Z�•` CONCRETE PEDESTAL BY DRILLER:Ely- ❑No S <br /> LOCKING CHESTER SOXiSTOVE PIPE <br /> 5 <br /> PROPOSED CONSTAVC TIONlDFpIUNO METHOD: MUD ROTARY AIR ROTARY AUGER <br /> _CABLE OTHER <br /> 1 HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLI.OWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IB 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IF ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001 40,11-M23. COMPLETE DRAWINO AT LOWER AREA PROVIDED. <br /> Blpned X T10. <br /> D.ta <br /> PLOT PLAN 1D—to So.I.1 Re.I. to <br /> 1. NAMFS OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br /> 2. OUTLINE OF THE PROPERTY,OIVWG DIMENSIONS AND NORTH DIRFCTION. 4 LOCATIONOF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED5. DIMENSIONED OUTLtNFS AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSSIOION F SEWAGE DISPOSAL SOF O8. <br /> S• LOCATION OF <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH As PATIOS-DRIVEWAYS,AND WALKS. WELLS WITHIN RAOIVOF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY <br /> APPScabn Aeaepl.A By /l� ]v <br /> D.I. I L ! L Ar <br /> Grout Impxllen By D.I. Pvmp In.Pxtl.n By <br /> Dw. <br /> 0-1—lbn IMpxllon <br /> D.I. <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE <br /> PEFIMITISERVICE REQUEST HUMBER INVOICE <br /> 4 <br /> Pub.Health Serv.-Enviro.173(3/96) <br />