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APPLICATION FOR WELLlPUMP PERMIT b � DO flzs�7_ <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ,y��r ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (� `� <br /> 20 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 TEAR FROM GATE ISSUED 4`''�L1� ` <br /> 610) <br /> ICompiiti In TTipskstel <br /> APPLICATION IB HERE BY MADE:TO THE SAN JOAGIAN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK OESCRIIBEO.THIN APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JOAQUINCOUNTY DEWL PMENT TITLE,CH R 9.1 1 1 b.3 AND THE STIANNDARDSI OFBANJOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH OMSION. <br /> JOB AODRES9IAR AI+Nf ` +��4 Y ��CITY �Lry�_--- PARCEL SRFjAPNRf,)l t <br /> OWNER'S NAME�y L ADDRESS a u l� -1 1 rJ.SQT�.�� PHONE <br /> CONTRACTOR i a ADOIIENB_ M'j�'(� '' LIC, MIONE i <br /> BUE CONTRACTOR ADORESSy _ �J� LIC1 51 � I PHONE I <br /> TYPE OF WELL7WMP: ❑ Na'W WELL ❑ REPLACEMENT WELL ❑ matirroRINO WELL R ❑ OTHER u11INBYALLATION ❑WELL SYSTEM REPAIR 11CROSS-CONNECTREPAIR 13 VAPOR EXTRACTVJN WELL! 1 <br /> 13 .p <br /> N.G Rrr H.P-- DEPTH PUMP SET FT. FIRST WATER LEUHL d <br /> {TYPE OF PUMPI ti Ir f Q <br /> OUT.Op-In" CE WELL 13R WU 6 GEOPHYSICAL WELL/ BOBONll <br /> �ESTRNCTION: Wal W <br /> INTENDED ViE TYPp-OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTMAIRIVATS ❑GRAVEL PACKIBIZE TYPE OF CANINOMTEEVPVC DIA-OF WELL CASINO p <br /> ❑ PUBLICWUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ mRIGATKINIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME f <br /> ❑ uowlo ma ( oaovr SEAL PUMPED: ❑Y. ❑N. CONCRETE PEDESTAL EY bRRLER:❑V.. ON. S <br /> APPROX.DWI"__ "A LOCKINO CHESTER EOXMIOVE PIPE <br /> PROPOSED CONSTRUCTIO"MRILUNO METHOD! MUD ROTARY AIR ROTARY AUGER_CABLE OTHELL_ <br /> 1 MEIEBY CERTIFY THAT I ItAVE PREPARED 114I8 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAUUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> RFOULATIONB OF THE BAN JOAORIIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLO✓IN0:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18186UED,1 SHALL NOT EMPLOY PEMSONB SUBJECT 70 WORIIJMAN'i COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING GIONATURIE CERTIFIES <br /> THE FOLLOWIFq: I CERTIFY THAT M THE PERFOWNANCE OF THE WLVK FOR WHICH THIS PEFMIT IE ISSUED,1 SHALL EMPLOY PERSONS BUEJECT TO WORIDMAN'i COMPENSATION LAWS OF <br /> CAUFORInA.' T PPUCANT 7p,CALL 24IN ADVANCE FOR ALL REQUIRED I PECTIONG AT Lxpi}4p.7A23. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blprv�d X _Tills �,nL . D.1P -7::n- <br /> PLOT PLAN Mrsw to Bad.l Bodo 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR DOUNOING 74E PROPERTY. •. LOCATION OF HOUSE BEWAOE DISPOSAL SYOTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,ORR"O DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE tHEIMOAL SYSTEMS. <br /> 7. DIMENSIONED OUTLINES ANO LOCATION OF ALL"WFING AND PROPOSED S. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT. <br /> S7RucTURE8,INCLUDM COVEFIED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPEWW OR ADJOINIIO PROPERTY, <br /> .-. <br /> i. i <br /> .. <br /> E; - --- <br /> E <br /> �s i HEA V4�4 7 <br /> .. ...... k.4Jd113 <br /> TAC IEP LH4 ,. <br /> DEPARTMENT USE ONLY <br /> Appll"tlan Aoamo d By D.N_ <br /> Grout In pe.tion Ey D.tsSJ A--9 Pw p 1n.peglon BY .•'—r DN. <br /> O..wmtI.n Irt.pmklen EY— Data <br /> I�f I t a_ <br /> Cemmmits: w �I. 6L <br /> r4S-, <br /> UNTING,ONLY: AID1' FACT <br /> ODES FEE INFO AMOUNT REMITTED CHECKSICASH RECEIVED NY DATE 10"IM1TISERVICE rioun'r MUMNERR INVOICN <br /> 1 lSa.oo I'7 213 ,�- d 12 �0 2 D37-3 <br /> 3 3 g <br /> Pub.Health Serv.-EnYiro,173(1197) <br />