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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICto <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 469.3420 <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 IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARD8 OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APN# 51m S. c4 w y 33 Clr,,_Q Ver rllp,"S . 0, PARCEL SIZE/APN/-G 0 q,ao- <br /> OWNER'S NAME /�S+2r n Fqr vr1 Se-C V l G1: ADDRESS Q0 poY 1160 �eSn'tJ. Q 93-715 PHONE# JIO/e7B3-0 3 <br /> CONTRACTOR VeO�Y1`ec- � 'su\AI 1k3 ADDRESS 1�Neytt'I) W�n 11106 <br /> cccek UC+I--N/-A_P14ONE ISI011 _" C64 <br /> Gres <br /> "-'1o N0 ems. G' u <br /> Bun CONTRACTORGress. „ S;4y n <br /> -� C ADDRESS t�;ne;E i c� RL1553 uc# 4o.J1D l_ 0-7 PHONE#510/3Lg-SBpp <br /> TYPE OF WELLIPUMP: 11 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ® OTHER CPT - G(b"j d6r S¢Yn "d <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# d <br /> (TYPE OF PUMPI 11New 11Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> M ` \ <br /> 11OUT-orSERVICE WELLI f+❑ GEOPHYSICAL WELL# ❑ SOIL BORING R <br /> IN DESTRUCTION:__ ►r1,o L!, C q C0 4�EC OR C C� �p on I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAiION>tN l - A <br /> 11INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION - 0 <br /> DIA.OF CONDUCTOR CASINO p <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINO/STEEtIPVC DIA.OF WELL CASING <br /> ❑ PUBLICIMUNICIPAL ❑OnIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> {Fs MONITOnINO I �iME 11 GROUT SEAL PUMPED: ElYea [IN. CONCRETE PEDESTAL BY DRILLER:[IYea ❑Ne S <br /> APPROX.DEPTH_ 90 Ty. LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONIORILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER­_,?� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN 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 PERMIT 18 ISSUED,1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'@ HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I.SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA' 1 APP AN UST CALL 24 HOURS IN ADVANCE FOR ALL RE'UN, <br /> INS ON 20414"2k. COM O AT LOWER AREA PROM O. <br /> BlOned X ' -� Tltle N(�Y"r� Data r� Z t <br /> " 050 < J <br /> PLOT PLAN(Draw to Soalel Soals­17Aq1`7 <br /> , 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEW//1GE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 9. DIMENSIONED OUTLINF.8 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 /> I_xzPT <br /> of <br /> DEPARTMENT USE ONLY a L9 G <br /> Applloatlen Amepled BY �/.f.7?� -), Date_ r1/�Q L O A," <br /> Grout Inspection By Date <br /> � Pump InaPeetlen By Data <br /> beavuctlen Impectlon By_. (�//e/'�v�L- `� Y Date <br /> Cemmerua:� ",e Za=& /i/Yt.O / � <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED By DATE PERMIT/SIERVICE REQUEST NUMNER INVOICE <br /> 0 <br /> Pub.Health Serv.-Enviro.173(3/96) <br />