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� APPLICATI"N FbR D4,,c� LLIPUMP PERMIT <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERV 2 ON <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 988, 304 EAST WEBER AVENUE, STOCkTON. CA 95201388 <br /> (2091469.3420 <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ORIGINAL , <br /> (Complete In Tripl'K:atel <br /> APPLICATION to HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1111H5.33 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODRESS/OR/APNI 30l Ihb/�B�e.�vllla(m �I u�"`{n,'pf-br i L'l —CITY—: RO ck-IV(•1 C-/y�l I,{-�P�A�RCEL SIZE/AMM <br /> OWNER'S NAME L Va��ILL//�S(�/ Iii I IBJ t-#14�/u�1 ADDRESS tP.A (/o///t- X73 7,6J/t/L�i�t PHONE:1 �L� �p <br /> CONTMCTOR ��j Uy� ADDRESS /")Z) /o me Ad IIC;F 185/6.- RHONE 00041` 7'00 <br /> SUB CONTRACTOR ADDRESS (ICI RHONE <br /> TYPE OF WELU /�y <br /> PUMP: IO NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> ❑Naw❑Fa.lr H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL 0 <br /> ITYPE OF PUMP( <br /> ❑,DVT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL! bf SOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 6PECIRCATIONS� A <br /> ❑ INDUSTRIAL p0 <br /> 1 OPEN BOTTOM DIA.OF WELL EXCAVATION n DIA.OF CONDUCTOR CASINO 0 <br /> ❑ DOMESTICIPRIVATE pl GRAVEL PACK/SIZE'9,3 an / <br /> TYPE OF CASING/STEELIPVC V C DIA.OF WELL CASING((r2 " 0 <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL B I SPECIFICATION 5CA q0 R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY 0r1,1L--r GROUT BRAND NAME E <br /> 10 MONITORING GROW SEAL PUMPED: ❑Ys ❑Na CONCRETE PEDESTAL BV DRILLER:®Va [IN. S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE/ S <br /> RROPOSED CONSTRUCTIONMNLUNO METHOD: MUD ROTARY AIR ROTARY AUGER V CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES ANI <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'t CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICI <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIE' <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR.WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS 0 <br /> CAUFORNIA.'_THHEE APPLICANTMOSST CALL/2q�IRIiS IN ADVANCE OR ALL REQUIRED INNSCTIONSA'T120014/S1223.. COMPLETE DRAWING AT LOWER ARA M( VIIDED. <br /> SIOmX As Thla vM?774� f / CllMPC/ <br /> Det.V If <br /> PLOT PLAN IDr.W to IMOO Gula -to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE OISPOSAI 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,INBVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY <br /> Applleetlan Accepted BY Det. ✓ ( Ara O� <br /> G,.w ImD.ctlen By O.t. Pu v Impeatlen By D.ta <br /> Omtrmtton Inspwt;on By - / D.te <br /> CemmenN: C� O / � w <br /> UU <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CABH RECEIVED BY DATE <br /> D (7 PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> �Q ) ✓ -7Q T <br />