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APPLICATION FOR WELUPUMP PERM D 6,Tt� T <br /> SAN JOAOUIN,4OUj4TY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 COPY <br /> NON-REFURDABEE PERMIT EXPIRES I YEAR FROM GATE ISSUED <br /> (Com0111181 <br /> APPLICATION 19 HERE BY MADE TO THE CAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT lete AND/OR <br /> INSTALL THE WON(DESCFU9E0.71118 APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAGUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1715.3 AND THE STANDARDS Of SAN JOAOUIN COUNTY PVBLUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADORESB/OR APNf 0'34 �d-s'J A, p rLG <br /> CITY l P RCE[BI E/APN,F <br /> OWNER'S NAME Q �aI Z1 C.• m:"y1 III ! �� , <br /> ADDRESS � RHONE <br /> CONTRACTOR r to ADDRE..21-16 1 SVi <br /> LIG. p. 21 RloNE,. !Q-2Gf, vgGb <br /> SUB CONTRACTOR <br /> ADORESS LIC# RHONE N <br /> TYPE OF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL BYSTEM REPAIR © CI11088-CONNECT REPAIR ❑ VAPOR EXTRACTION WE f <br /> LL <br /> J <br /> {TYPE OF PUMP ❑NawD�P�, H.P. DEPTH RUMP BET FT. <br /> 1 FIRST WATER LEVEL 0 <br /> I <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL f Olt BORING <br /> DESTRUCTION: <br /> e <br />! INTENDED USE TYPfi OF WELL <br /> CONiTRUCTION SP£CIFICATIOMi <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION - A <br /> ❑ DOMEBTICIPryVATE ❑GRAVEL PACKISUE TYPE OF CASINGISTEEIIPVC DIA.OF CONDUCTOR CASING_ 0 <br /> ❑ PIMJCIMUNICIPAL ❑II)RI 01A-OF WELL CASINO - O <br /> DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑ IMUGATIONUAG ❑OTHER <br /> go GROUT BRAND NAME <br /> R <br /> GROUT REAL INSTALLED BY MOHITORINO GROUT REAL PUMPED: ❑Y•• ❑Na E <br /> APPROX.DEPTH <br /> CONCRETE PEDEL BY DFJLLER:STA ❑Yr ❑Ne g <br /> LOCKING CHESTER SOXIe'TOVE RPE <br /> PROPOSED CONSTRUC7IONUDRILLING METHOD: MUD ROTARY AIR ROTARY (/���,,, 1_ _, 5 <br /> AUGER CABLE OTNER�W[-+�'�3{,� ."r- <br /> 1 HE9E8Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WTTH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWMG:'I CERTWY THAT IN THE PERFORMANCE OF THE WOR(FOR WHfCH <br /> THIS PERMIT 18 ISSUED,I SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIFUNG OR SU"ONTRACTING SIGNATURE CERTIFIES <br /> 7HE FOLLO CERTIFY THAT RI TI1E PERFOPAIANCE OF THE WORK Foq WHICH iHiB FERMI 18 188VED,1 SHALL EMPLOY F'ERSOMS SUBJECT TO WORKMAN'i COMPHiNSAT10N[AWB OF <br /> CALIFO A FIT MUii CA 24 HOHAti N ADVANCE TOR A REOUMED iMiPFCi/ONi AT 13Oi11if-f4 0111PLET£DHA A7 LOWER AREA PFIOVI p,, <br /> L <br /> _ Qf ti <br /> !. NAMES OF STFIEE78 OR ROADS NEAREST TO OR BOUNDING ERIE pigPER7Y�re1 8e+•1•�_•to � ..y <br /> ?. OUTLINE DF 7HE PROPERTY,GRAFRO DIMENSIONS AND FIDRTN DIlIECTIOH, 4. LOCATION OF HOUSE SEWAGE dePOSAL BYSTEM OR PROPOSEDRI <br /> 7, DIMENSIONED OUTUNF.8 AND LOCATION OF ALL EXISTING ANp PUIOPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> STRUCTURES.WtVDINO COVERED AREAS SUCH AS PATIOS.DVEWAYS.AND WALKS. i. LOCATION OF WELLS W/TMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOIMFq PRGFEM, <br /> • <br /> Vt <br /> . 7 <br /> t <br /> Br <br /> Appll••tlen ADEPARTMENT U811 ONLY <br /> e•e•1ad <br /> Grout rmpeptlen By <br /> Date Pune lnpeelfen By <br /> Orintetbn tn•veellen By <br /> bite <br /> CemmnH•: Z ACCOUNTING ONLY; AID# FACE <br /> FE CODES FEE IWO AMOUNT REMITTED CHECKI/CASH RECEIVED BY DATE <br /> Pf3i1NITUiEAVICE REQUEST NUMBER INVOICE <br /> Pub yeafth Sere,-EnvirG.173(1197) <br />