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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES <br /> %t+" ENVIRONMENTAL HEALTH DIVISION <br /> RO,BOX 388,304 EAST WEBER AVENUE,STOCKTON.CA 95201388 <br /> (209)488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete IR Trl l{eetl) <br /> APPUCATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCNBEO.THIS APPLICATION 10 MADE IN COMPUANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9. <br /> 9.11115.9 AND TILE STANDARDS OF SAN JOAQUIN COUNTY e.P/UBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESMM APHI '-.J C _ ti� C�r�w�1'--J-I}'y�G/ CITY�!qo/k-?LJ•-�C �J /p�.P�.A�RyC�EL SIZE/MNI <br /> OWNER'S NAME �(LG J 1 _ADDRESS �I7�A G+LC% iJ4N RQEj+O(rrrlN LTJ 2'T -ONE#- qk /y,Z�S(�Y'j <br /> CONTRACTOR "' I/?StitJTn P T+'�' yT71.te IR2 ADDRESS '/. ,x1 M, R� K z�v PHONE 111/-9 <br /> -9 <br /> [`� � <br /> sue CONTRACTOR�1 PdJ TrT/�XG�e r»-r<"ey. HJT, ADD-108,7g25 11CF`? PHONE I�.�CfI• SL',S'f}`C <br /> - 7 <br /> TYPE OR WELSRVMR NEW WEU. ❑REPLACEMENT WELL ❑OTHER' N <br /> INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL I <br /> R VPE OF PVMPI 13NM. <br /> mw❑RJr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL I ❑ SOIL BOMNO B <br /> ❑DESTRUCTION: <br /> INTENDED SE Y►E OF W CONfTRUCTiON fRECIFlCAiIONe o/ A <br /> ❑INDVRRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION pl DIA.OF CONDUCTOR CASINO 0 <br /> 11RN <br /> DOMESTICVATE C <br /> PE❑GKAVEL►ALK/SIZE TYOF CASINO/.TEELMVC T'V G DIA.OF WELL CASINO <br /> ❑PUSLJCMURIICIPAL 11 DRIVEN DEPTH OF GROUT SEAL ID 20 tPECIFiCATbN d A <br /> 11IRRIOATION/AG ,�OTHER GROUT SEAL INSTALLED BY.S.Idol ret.y�TD�b•lYl:o..fIROVT RMANO NAME E <br /> PMONRORINO GROUT SEAL PUMPED:❑Y"—r�: ❑N. / CONCRETE PEDESTAL SY DRILLER:❑Y« ❑N. S <br /> APPROX.OERH LOCKING CHESTER BOX/STOVE RPE)) I,,��+-�IE S <br /> PROPOSED CONSTRUCTIOWDRILUm NO METHOD: MUD NOTARY APDTARY AUGER M/ 'SC/IeOTHER <br /> 1 HERESY CERTIFY THAT 1 HAVE PPIEPAKD THIS APPIJCATION AND THAT THE WORIC WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> PEOULATbNS OF TNF SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGS•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PEAMIT le ISSUED,I W.W.NOT EMPLOY PEP40N.SUBJECT TO WOAXIMAN'f COMFOISATION LAWS OF CAUFORINIA.•CONTKACTOR'e HIRING OR SUetONTRACTINO SWNATVRE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT It ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPIPENSATION LAWS OF <br /> CAUFOP"A'1�'�./Z� �ANT/ 24 HOURS IN F/�itrADVANCS FOR ALL"GUIRIw�Y1PSCTI XS AT!��4 4444422.6".f'.1 �. E dUW7N0 AT LOWER AREA TO <br /> SblMrr% DEI. IKJ" <br /> PLOT PLAN IDI.w It.S.A.)$..I. -le <br /> I. <br /> NAMES OF STREETS OR POADI NEAREST TO OR BOUNCING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING OIMENSgNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> S.OIMENSOONED OUTUNFS AND LOCATION OF ALL EXISTING AND RROFOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUMORED FIFTY FT. <br /> STRUCTURES,INCLU04NO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK.. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> tj w..l <br /> sGIJTrI cENTP:R srrtr.Er 3 <br /> . GRAwru.PERUIRIu- <br /> RIF Tml,.Ea MIEO IxxRT ITI,NP Ii`T <br /> ---SSS IFVCT. <br /> .. ,\ t_.J 1' _ 7 N Ivntx Tx.vn(xx, Inilmtl uMU ltx.,Inn <br /> •'\ I IRM nI.: I TP , � nr vEI,IIMEN�1 MTxN,nisx,�TM'MI UDI <br /> I\ne BTR. Tn, <br /> r TEoB-� ,,..•� <br /> TULe <br /> -- SITE MAP <br /> --- <br /> cx� F..T..I.I.t.,,.. <br /> vl.,EVlni _ <br /> f•"t"'""". t. .•w TIMp�ECt .F.nn In sglxlF 2 ' <br /> OEIMTMENT U.E CNLY <br /> APP11-1—A—td d By <br /> G,EVI 1—11—BY DEI. PT p In p—I.n BY II DEI. <br /> D-,,—II.n 1,MP 11—.T DHE <br /> C.mm.,.: in I IL ns r y�L��s :Wlo96 -(s\1— 0(022 w/ vId oUsS <br /> ACCODUITING ONLY: NDI FACT <br /> PE CODES Fill INFO AMOUNT KDAITTED CHECKSICASH RECOVED■y DATE POMAIT/SF71V10E REQUEST NUMBER IHV OIC[ <br /> I 05 3 lo• 013 �, <br />