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APPLICATION FOR WELLIPUMP PERMIT v�o^ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i JAN Z E .::; ENVIRONMENTAL HEALTH DIVISION <br /> P.0 BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201-388 <br /> (209)466.3420 <br /> J NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Compute In Trlplkats) <br /> APPLICATION IS 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 <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNI 1.)05 11!PPgt I-Ze 1.1 aurin iio11- Dr CITY <br /> nStockton <br /> 'IPARCEL�IBIZE/APN1 �T/n1 <br /> OWNER'SNAME nnevron [roduct5 1J.S.4. ADDRESS 6001 13011ir1CJF�r 4;Zil'[JIl r�11 PHONE�1 O-3 X2_C <br /> CONTRACTOR Cer, j1ity c ,miller, STC ADDRESS 1 050 f,larina '.Jay :&;gith 5171 idlle+r 7? •j�cl <br /> ---a �taztnat Drillinl ��' .-5 i <br /> SUB CONTRACTOR ? _ "'�' ' �" µ-`�i ci 0/0 siv <br /> ADDRESS - PHONE 05"7Z. ASI <br /> —_ --ti - C 4 . (t - �(1 CIS✓ -L <br /> TYPE OF WEIUPII MP: ❑NEW WELL ❑REPLACEMENT WELL -©-MONrro RING-WE[l%`--5-' EI OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR Q VAPOR EXTRACTION WELLS <br /> ❑,N—❑P—I, kl``P }; ,I DEPTH PUMP SET'1 FT. t .FIRST WATER LEVEL <br /> (TYPE OF PUMP)1 a F [ . �,� ..l i. , <br /> ❑ IRT-OF-SERVICE'WELL ❑GEOPHYSICAL WELL S ^❑ SOIL BORING <br /> ❑DEETRUCTION: <br /> INTENDED UEE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 1 U" :'i 12 i 1 DIA.OF CONDUCTOR CASINO <br /> ❑DOMESTiC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEELR'VC DIA.OF WELL CASINO <br /> 1 <br /> ❑PUBUCR.IUNICIPAL ❑DRIVEN , DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑IRRIGATION/AO P OTHER GROUT SEAL INSTALLED BY GROUT t �1�.�;:11 C GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED:❑Y. M No CONCRETE PEDESTAL BY DRILLER:❑Y.. [IN. <br /> APPROX.DEPTH A 3 5 w <br /> LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONS7RUCTION/DPoWNO METHOD: MUD ROTARY AIR ROTARY AUGER X 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 <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S 81ONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WI <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTO R'e HIRING OR SUBCONTRACTING SIGNATURE CERTI <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAW' <br /> CALIFORNIA.' THEA NT MUST C/LL 24 NOV/RS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1208)4"3421. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> slonw x �" <br /> Ke r�I LII-I(!7.1 y SWT PUN ID—to Sc N.)Sul. J 3 <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 OUTUN ES 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 /> _.... <br /> Q <br /> v ( --� _ <br /> ... <br /> j <br /> F 1. <br /> J <br /> ... <br /> .......... _ <br /> 7 1:1Y6 <br /> T <br /> DEPARTMENT USE ONLY > / <br /> Apple—I.,Aeo.ptw D.te <br /> Ar.. <br /> O,out Imp—lon By Dat. Pump In.p.tlon By D.I. <br /> D--fl—Im tlon By <br /> O.te <br /> C.mm..t.: ��ut r r1�/ t1i> i i ls'l 'Z r.c, .i t f a 4 L. Il-L I I I.15 qt <br /> ACCOUNTING ONLY: AIDS FAC, <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC KIlCASH ftECDVED SV DATE P61MIT/SERVICE REOUEJT NUMBER INVOICE <br />