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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 95201.388 <br /> 12091 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (comphata in Trip?katnl <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115,3 AND THE STANOAFOS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APNX CO'Y �,/�[ C_ . PARCEL SIZUAPNR , <br /> OWNER'S NAME -C-- — __ADDRESS SPyT I N '/•� PHONE t <br /> CONTRACTOR ADDRESS 1� LICPHONE#9�""�'�^'-'1 <br /> BUB CONTRACTOR ot ADDRESS LICX PHONE X <br /> TYPE OF WELL/PUMP: ❑NEW WELL ,.�❑REPLACEMENT WELL Cl MONITORING WELL X 13 OTHER <br /> ❑INSTALLATION $15>WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WE �„�_ ✓ <br /> ❑New❑Rspdr HR. DEPTH PUMP SETLC�0_FT. FIRST WATER LEVEL—! O <br /> ITYPE�NIPI <br /> ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WEU X ❑ SOIL BORING B i <br /> I <br /> []DESTRUCTION: <br /> INTENDED USETYPE OF WFil CONSTRDCTIOXSPEIW+CRIIONS A <br /> E3 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> pOMEbTICRRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINOISTEELIPVC DIA.OF WELL CASING D <br /> L SPECIFICATION N <br /> pUBUCI{#VNIC'PAL ❑DRIVEN DEPTH OF GROUT SEA <br /> ❑IRRIGATION7AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME � E '� <br /> ❑MONITORING GROUT SEAL PUMPED:❑Ys ❑Na CONCRETE PEDESTAL BY DRILLER:13 Yr 13 N. ` S T <br /> APPROX-DEPTH LOCKING CHESTER BOXISTOVE PIK 1 8 a ' <br /> PROPOSED CONSTRUCTIONMF"NG METHOD:MUD ROTARY AIR ROTARY AUG J CABLE OTHER <br /> I HEREBY 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 SAN JOAQUIN COUNTY. HOMEOWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW.FOR WHICH"J <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECTTO WORIOAATYs COMPENSATION LAWS OF CAUFORNIA.'CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES 1 <br /> THE FOLLAWI 'I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IBSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION WS OF Dg <br /> CALIFORN HE APPUCANhILTOST CA tLL HOURS IN ADVANCE FOR ALL REQUIRED I�ii►C�\�JI/O/LNSf�AY 12MI 411*4423.COMPLETE DRAWING AT LOWER AREA PROVIDED 1 <br /> slprved X _ {� �� Tkb \ /L\I/„J' Wle -I I� <br /> PLOTPLAN ID-to Seale)Sc1e "tc <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR.BOUND.THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OFTHE.PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. Q <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 /> V _ <br /> ......... ., <br /> •�.. <br /> d <br /> . �;.. <br /> ,� .. <br /> I t °• <br /> DEPARTMENT USE ONLY 11 <br /> Appli-tt—A-wwd BY / Dere l Area_ <br /> Grout lropeetie By,Date PIInP Iropactlan BT <br /> Deatrwtan lr»paelloA BY <br /> Dar <br /> Ce._.: <br /> ACCOUNTING ONLY: AID# FALX <br /> PE tObES FEE INFO AMOUrvT REMITTED HfC 'CASH RECEIVED BY DATE P61MIT1aERaTINVOICE- jo ZL <br /> ISE 9 <br />