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APPLICATION FOR WELLIPUMP PERMIT ZuP\ <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON. CA 96201.388 <br /> 12081 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICOFOPMU in TI*Iieatal <br /> APPLICATION IS HERE BY MADE TO THE SAN JaADUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED,THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER <br /> �9-11115.3 AND <br /> ��THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JO8 ADURtSS/OR APN,f ■LA `!'I�. 4µh 1 • '�'�CL^_ r. j CITY !PARCEL SILEIAPN/� � <br /> C_ <br /> OWNER'S NAME ADDRESS F �^ PHONE I <br /> CONTRACTOR L �/ -_ -ADDRESS I--'/MJF (fes jr/llJJJC/ PHONE# TS <br /> SUB CONTRACTOR_ -� xt _ ADORESS_J�� C J`� f:.Jo►-V!�JIC/ PHONE f <br /> TYPE OF WELLiPUMRt ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL K ❑ OTHER <br /> ❑ iNSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTKJN WELL s J <br /> ❑New❑Pepalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMPI , ❑ OUT-OF- RVICE WE 11 GEOPHYSICAL WELL 0 BOIL BORINr3�j% n?ly k B <br /> �DESTRUCTION:� MY Iti -� [ <br /> INTENDED USE TYPE OF W%L CONSTRUCTION SPECIFICATIONS A <br /> Q INDUSTRIAL ❑OPEN 80770M DfA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTICIPFIVATE ❑GRAVEL PACK)SI2f TYPE Of CASING/BTEELIPVC DIA.OF WELL CASING 0 C <br /> S <br /> ❑ PUSLICMIUNICIPAL ❑DRIVEN DEPTH OF GROUT REAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY ::ROUT BRAND NAME F <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Y. ❑Ne CONCRETE PEDESTAL BY 13FULLFR:0 Yr ❑Na S <br /> APFFIOX.DEPTH LOCKING CHESTER SOXISTOVE RPE s <br /> PROPOSED CONSTRUCTIONIDRIU.IN13 METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER r n <br /> r� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WfTN BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I&HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFOFftA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORT(FOR WHICH THIS PERMIT IS ISSUED,1 SHILL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF rte' <br /> CAUPCIMA.- TIP APPLICANT NI 7 A!1�!f�OLRiS IN ADVANCE FOR All REQUIRED! TIONS AT f21w1+00-447!/3.ICrOOMPLEfE DRAWING AT LOWER AREA PIROVIOED.f� <br /> SIOn..i X _ Tlll. ` �7 1 YL� Date ` 3 �S <br /> Id <br /> PLOT ia.AM IDraw!o Scrfel Sale 'to <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPEFITv. 4. LOCATION OF HOUSE SEWAGE DISPOSAL. STEM OR PROPOBEP <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTE ii�7 <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WfTHIN RADIUS 4 bW#jUNb*6 LIPTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WALKS. ON THE PROPERTY OR ADJOiNWG FROPERTY. <br /> n <br /> _ a6LGt. <br /> - _ <br /> ` 1w10M raw <br /> ROAD <br /> C',Yx► % . <br /> DEPARTMENT USE ONLYSC� <br /> Applloatlon Accepted By� — /, „! A,.,I T <br /> Grout I—pecrion By bare Pump Inabectlon By _ O.to <br /> De.trucllon Impaction By_ pate (0 %"i � <br /> ce u L-_ / ri ll;L <br /> �ilt9TZ�ui L—"L o e�.?f U� �..�� - } PC L/ rk�t r.� v/7G•r �Cr {.�1 QC1 fYY <br /> ACCDUNTIN:1 ONLY: ARG# FAC* 9l9 (7 Cc <br /> � s✓ <br /> ^ L JO i. t�� A, A', � yf <br /> PE CODES FEE INFO AMOUNT REMITTED ASH RECEIVED BY DATE POVIAITlS91VICE REQUEST Nu1M8EF1 INYUICE <br /> Ra Roy31 <br /> dr'�A­ <br /> Cc ' <br />