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APPLICATION FOR WELLJPUMP PERMIT j ' <br /> ►V SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESIA L.L„L PU�//�� <br /> ENVIRONMENTAL HEALTH DIVISION �+�Yt <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <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 WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TIT .CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH OMSION. <br /> JOB ADDRESSOR APN# S Fµ LL-•' dTYS PARCEL SIZE/APNI �•7� <br /> OWNER'S NAME r ADDRESS b• ��PHONE R lJ-�� <br /> CONTRACTOR �i -d ADORERS a.� UC8 0A) ! PHONEjIi' <br /> f� <br /> RUB CONTRACTOR ADDRESS UC# <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL# J <br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �J../J� R A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM J DIA.OF WELL EXCAVATION / V DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTICR'RIVATE ❑GRAVEL PACK/BIZE �1 _' TYPE OF CASINO/BTEE(JPVC / 11 OIA.OF WELL CASINO O <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN r Y '1 ) DEPTH OF OROUT SEAL �"� SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER J' v •�•/ GROUT SEAL INSTALLED BY '� GROUT BRAND NAME f'(Jr�17�Y L-� E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑Nem/ CONCRETE PEDESTAL BY DRILLER:❑Yw [IN. S <br /> APPROX.DEPTH L-tJ LOCKING CHESTER BOX S <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY A _i CABLE OTHER <br /> 1 HE9ERY 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 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.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTIIG SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE V401W FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE <br /> MANN MUST CALL 2 IN ADVANCE FOR ALL REQUIRED INSFE+CTIO AT(2//pe1 4e;-9422. COMPLETE DRAWING AT LOWER AREA PROV/ID Lqq <br /> X !A/i'•^��ll/Y/`�( Title Oete / <br /> -�' PLOT PLAN(Drrw to SoMa)Bade 'to <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.OIVMM 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 /> i CE <br /> IVSD.':: <br /> DEC <br /> bHra,iOP^' <br /> _. ...:. <br /> PUBLICt <br /> ENVIRON�7 <br /> DEPARTMENT USE ONLY <br /> Appltadlen Accepted By Data Mer _ <br /> O.eut Inepeetlen BY Date—�Pump Ineoeetlen By vete <br /> Doevla3ft.Impeation 13 - Date <br /> Cemmenlr <br /> ACCOUNTING ONLY: AID# FAC/ <br /> PE CODES FEE INFO AMOUNT RREMITTED CHECK#ICASH RECEIVED BY DATE, PEWIT/SERVICE REQUEST NUMBER INVOICE <br />