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4 <br /> APPLICATION FOR WELLIPUMP PERMIT n O S-el <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 988, &A EAST WEBER AVENUE, STOCKTON. CA SIMI.388 <br /> (209) 468.3420 <br /> NON-REFUNDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in TH POC111te) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR 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 D'dISION. <br /> JOB ADDRESMR APN# J111C:�C �' f;t ( �` 4CIT-Y. / E/R T PARCEL SIZEJAPNN _ <br /> OWNER'S NAME_ '• I' .. N ADDRESS4,k IANf PHONE#—t`ir "„�„yL� <br /> CONTRACTOR ' 1!° / ,r I ; ADDRESS r.'a' /J IJC .� J.-3 PHONE/J6 7 <br /> SUB CONTRACTOR �-., ADDRESS LIC# PHONE i <br /> TYPE OF WELUPUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER_ <br /> ❑ INSTIL1,11-ATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL i ,I <br /> I New❑Stegall H.P- DEPTH PUMP SCT <br /> �&O FIRST WATER LEVEL p <br /> ITYPE OF PUMP), / <br /> ❑,OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL i ❑ SOIL BORING g� <br /> ❑DESTRUCTION; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& .;. <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION UFA,OF CONDUCTOR CASINO <br /> PI DOMESTICIPRNVATE ❑GRAVEL PACKIS42E TYPE OF CASINGISTEEUPVC ' r DIA,OF WELL CASING S r <br /> 11PUBU4sCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL J� _ SPECIFICATION <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY fid - GROUT BRAND NAME ti p 1 <br /> D MONrTORINO GROUT SEAL PUMPED:,W ❑Yr Ne CONCRETE PEDESTAL BY DRILLER:W,Y. ❑Na <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE_ <br /> PROPOSED CONSTRUCTIONIDRIWNG METHOD: MUD ROTARY_ ' '—AIR ROTARY AUGER_ CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL 6F DONE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSEO AGENT'S SIGNATURE CERTIFIES THE r'OLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CE <br /> THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK.FOR WHICH THISPERMIT18 ISSUED,I SHALL EMPLOY PER80N8 SUBJECT TO WORKMAN'S,COMPENSATION LAW8 <br /> CALIFORNIA.' THE ANT MUST C 24 HOURS IN ADVANCE FOR ALL REGMIM IN! f ONe AT fn'A1 X3422. COMPLETE DRAWING AT LOWER AREA PROVIDED, <br /> Slpned X .,�'r�' •'b'I ..kms” Title E 197r <br /> Date <br /> PLOT PLAN IDrow to S�Aal Sada '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,GIVING 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 /> �� o slur <br /> DEPARTMENT USE ONLY <br /> Appllcellon Aee+pmd Hy_ L Date _Me•_ . <br /> Grout In+gectlon By. Z Q.�^ �I � <br /> Defe �pump In+pectlon By DetafJ i-f�-1"f/� <br /> De+trtxitlen Irapect3on By Date <br /> Commentr <br /> AC C.UNTING ONLY; AIDS <br /> FAC# <br /> PF.CODE& FEE INFO AMOUNT REMITTED c EC ]CASH RECEIVED SY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3 Aft <br /> r X00 � �a o�Fo7 rv5 <br />