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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 x J <br /> (209) 468-3420 <br /> MOIL-REFUNDABLE PERMIT E%PIRER f YEAR FROM DAZE ISSUED <br /> ICemplete IS,TrlpReeto) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1118.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSMR[AAP`NO& ! .{n a n G1 �� `nI)1 CITY.-J yam.GLf PARCEL SIZEIAPNR <br /> OWNER'S NAME.-v_ f _L. n 7. I Ir �..,�._ ADDRESS PHONE E <br /> r^• / f_ <br /> CONTRACTOR I cvRE <br /> ADDBB D f()f Wo-f& r IL`�{�Iny, uclt i& A PHONE F-1D <br /> 7 /' J p6 T-r <br /> PUB CONTRACTOR_aj A P..0 Lan LL'aynd 11nc ADOREse,�n�t,J,Ikb G,•i LIC# PHONE' 4- (J[1'2zl <br /> TYPE OF YYfLLRUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL r ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ,I <br /> ❑New❑RW* H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p <br /> TYPE Of PUMPI <br /> ❑ OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL# A SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WEU; CONSTRUCTION 4KC1F1CATIONS ` A <br /> f ! <br /> 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINOUc'LCJj O C,JZ <br /> ❑ DOMEBTICMMVATE ❑GRAVEL PACK/SIZE TYPE OF CABINO18TEELIPVC NJ 4 DIA.OF WELL CASINO_ -aj D <br /> ❑ PIIBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL C4.. C,.... nA P, SPECIFICATION `"" B <br /> ❑ MRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MOHRORING f GROUT SEAL PUMPED: ❑YM [IN. CONCRETE PEDESTAL BY DRILLER:❑Yw (IN. S ~ <br /> APPROX.DEPTH � � LOCKING CHESTER SOk187OVE P'IK'E S <br /> n <br /> PROP'OeSD CONeTRt/CT10NfbgLLING METHOD' MUD ROTARY AIR ROTARY AUOER �CABLE OTHER -r <br /> S <br /> 1 HE9E01Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL SE DONE M ACCORDANCE WITH BAN JOAGUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUM COUNTY, HOME OWNER OR LICENSED AGENT'S BIGNATURE CEFrrWfEB THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE WOW FOR WHICN <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS 9U&WCT TO WORKMAR'L COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S AIRING OR SUB-CONTRACTING SWMATURE CERrIREB �.. <br /> THE FOLLOWING: 'i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSON8 SUBJECT TO WORKMAN'S COMPENeAT/DN LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST C LL 24 HOURS IN ADVANCE POR ALL REQUIRED INSOWTIONS AT fOel lee,7/2]. COMPLETE DRAWING AT LOWER AREA PROVIDE <br /> D <br /> . <br /> ewmd X C-sYD'n!1 ){�AA.i�Dona*% TIB.�,�J 4/ <br /> PLOT PLAN(brow to Saolel Baolo 'to <br /> 1. }TAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROR'OBED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE IXOPOSAL SYSTEMS, <br /> G. DIMENSIONED OUTLMMEB AND LOCATION OF ALL EXISTING AND PROPOSED E. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOIN ING PROPERTY. <br /> cr <br /> 35 <br /> u)11 5 <br /> PAS <br /> MAY 12 <br /> SAN JOAc-';IN COUNP, <br /> PLiEL.1G NEALTN cEF1111CimS <br /> ... -: 1VIFIF w',yIVEflTAL HMTH D1VISlt„% <br /> 1 <br /> �4 <br /> —may D"ARTMENT US!ONLY <br /> Awlkstlon Ace led BY �K+i �/l. 1 Dole <br /> Mout Impoalten SY Dots, Pump Imp 11 n Sv /7 Oslo <br /> baotrmllan tmPoctlon BY Dote <br /> Ca monto: '5`3-71 1N )j D 01?-'r641 7-6 P <br /> ACCOUNTING ONLY: AIDN FAC# <br /> FE CODES FEE INFO AMOUNT RVATTIE VAC41CASH RECEIVED BY GATE PERMITtSITVICE REGUEet NUMBER INVOICE <br /> 7�2- SQ ! i� <br /> 2R of J-0l <br /> Pub Health Serv.-EnArG.173(1/97) <br />