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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE. STOCKTON, CA 95201388 ' <br /> (209) 489-3420 <br /> NON•REFUNNABLE PERMIT OMRES 1 YEAR FROM DATE ISSUED <br /> MA"iao6 in TripTimml <br /> f APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PaWrr TO CONSTRUCT AND/OR INSTALL THE WORK DESCRI8ED.THIS APPLICATION IS MADE IN COMPLIANCE VVIT}�SAH <br /> 4 JOAOUIN COUNTY DEVELOPPME•N�V TRLE,CHAPTER 9-1115.1 JA�ND THE STANDA/RDSS OF SA,(N���JOfAMom COG � PUBLIC H 7H SERVICES.ENVIRONMENTAL HEALTH DMHWN. <br />{ JOB ADOREB&OR APW 1-"�f'r` `c1 +(`'dV� !�'� ki 'I`!u�/ =�� �cY jU�E I`y"'�a CITY CC��ao��Ef�-I� PARCEL BMAPNs ' <br /> OV670 "S NAME cov,"j= "S -in �a'S �.•,� i '2 �, <br /> rc IY �D0RE86 I'Vo ?e•lfh, lPHONF t(6 - s7 <br /> CONTRACTOR •Y Ar/°/l7`�P.� �yL� "��[([� ! J.� --f c"u, 'j /' p. f 7 1 <br /> ADDRESS I III I /'�Aid-y�yt �p.@', '!"F LIC! r�''G/O ! P'HONE I <br /> SUN CONTRACTOR Jo;�: 11 U,/i Yl.r ADDRESS ;Q. /, 3 fv <br /> TYPF <br /> OF WELLIPLIMPNEW WELL 13RPL <br /> EACEMENr WELL ❑ MoNrrGRINO WELL OTHER <br /> Q INSTALLATION ❑WELL BYSrEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR E)MgACTTON WELL, J <br /> 13 mw❑Rewk H.P. DEPTH PUMP 8ET F'r. FIRST WATER LEVEL <br /> TYPE Of PUAHPI a.. <br /> fin✓ ❑ our-w SERVICE WELL ❑ GEOPHYSICAL WELL, <br /> ®De;BTRucTIGN: r res,�L+�� ISy1�'�r � BDR BORLNO •. 8 i <br /> INTENDm use TYPE OF WELL CONSTRUCTION SPECp4CAT[ONA <br /> A <br /> ❑ INDUSTRIAL ❑OPEN BO•rrOM OSA.OF WELL EXCAVATION DIA.OF CONDUCTOR C48M _ <br /> ❑ DOMESTICJPRIVATE ❑GRAVEL PAcfmn TYPE OF CASMAITEELPVC DIA.OF WELL CASINO O <br /> ❑ P/BIIClIIAGNKxPAL ©DRRlEFH DEPTH OF GROUr SEAL SPECIFICATION <br /> ❑ BRAOATIONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E' <br /> MONITORINGYw ' <br /> GROUT SEAL PUMPED: ❑ ❑Ne CONCRETE PEDESTAL BY DRUM❑Y. <br /> ON. <br /> S , <br /> APPRO]L DF1TH LOCKING CHE917M BOX/STDVE PIPE S <br /> PROPOSED CON91IGCSIO1111DRILLINO METHOD; MUD ROTARY AIR ROTARY AUGER_��CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATmm AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AHD <br /> AI TPONB OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S WGUATURE CERTIFIES THE FOLLOWING:'T CEfCTIFY THAT IN THE PE7LrORMANCE OF THE VVQq(FOR WHICH ' <br /> T. UffT BS ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TD wommAN•a GoMPHHIiATON LAWS OF CALIFORNIA.' CONTRACTOR'S HmNG OR sua?CONTRACTING SIGNATURE CERTIFIES ' <br /> THE r OLLOWING: 'I CERTIFY TIIAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIO P&mrr BB ISSUED.I SHALL EMPLOY PERSONB SUBJECT TO WOMMAN'f COMPO"Ar1ON LAWS OF <br /> CAUPORMIA.• Tl1E/1PFLICANr Gar CALL,24 HOLM IN ADVANCE FOR ALL MQURM BpPfC17p AT 12001�3►35. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blprrd X / '� T.. V-e xj 'r Den 1 b 6 f <br /> PIJ7T PLAN tDr.w to BeWH Sglr_ -1 •t60o <br /> 1. HAMEB OF STREETS OR ROADS NEAREST 70 OR SOLRHOMG THE PROPERTY. 4- LOCATION OF HOUSE SEWAGE DISPOSAL,SYSTEM OR PROPOSED <br /> %. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED GVTUNEB AND LOCATION OF ALL EXISTNG AND PROPOSED S. LOCATION OF WELLS WrTMN RACIOUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERrY OR ADJOINING PROPSITY. <br /> E - - - - <br /> =.................... <br /> ::......:.......... .. .. .......... . .. . .._ .. <br /> .. .: .. ' .........r ;..... ... ' r <br /> DwANTMENr UBE ONLY <br /> 2 <br /> ACOBmrtlan Aneepred By I.— !U r�• �� Mir � �• { <br /> drool IeNP@Ctkx 8y Oete '4r/ PIn+P k... .BY Oeste <br /> Dammtlen bused m By Date <br /> CemTentr. <br /> t <br /> 11 .olpmNO ONLY: AID* FAC, <br /> � _ I <br /> ` FS",a FES INFO AMOuNT Rl3YrTTm CHBCK,1CAaH Rw8VED BY DATE mwmff1aERVICE Redumr Al UMB011 BNOICE <br /> bb <br /> 37 <br />