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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SER S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201.988 <br /> (2091 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - I <br /> l�MPO <br /> oligarej <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT IAND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DFWLOPIM�ENT TITLE,CHAPTER 8-111$.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SFRVICEB.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNI V ut L�,�, rte( I-V, <br /> r,1 CRY PARCEL SRE/ARNP <br /> OWNER'S NAME_ SL111 1 � - • L.� L � I <br /> }� Ta .a ADDgE68_PpLI GJy, 4 )/ Z L( �l0 PHONEo)L�Y-Ll(F:i <br /> CONTRACTORtFr'la Wr. (I„mayh.C- ADDRESS /S/l HYWc Kms: YYIh-1 'YCL LICI�(�B\'I�o> <br /> SUBCONTRACTOR 1-LAC /� L� T �• PHONS49W31;'5-R6y <br /> ADDIase 1 J�y YTId uG L� Ec.o=1� <br /> TYPE OF WEUPUMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I <br /> ❑ LATION ❑ OTHER <br /> INSTAL <br /> ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> ❑New❑Revelr N.P. DEPTH PUMP ✓ <br /> TYPE OF PUMP) <br /> BET FT. FIRST WATER LEVEL 0 <br /> rt1 p 13OUT-OF-SERVICEWELL El GEOPHYSICAL WELL I SAIL BORING <br /> LL DESTRUCTION. !U-•.�1 �( <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 11 INDUSTRIAL ❑OPEN BOTTOM A <br /> DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO <br /> ❑ DOMEBTICPRIVATE ❑GMVFL PACK/SIZE D <br /> TYPE OF CASING/STEEL/PVC DIA.OF WELL CASINO <br /> 11 PUBLIC/MUNICIPAL ❑DRIVEN O <br /> DEPTH OF SNOUT REAL SPECIFICATION <br /> ❑ IRRIGATION/AG ElOTHER R <br /> DROIT REAL INSTALLED BY GROUT BRAND NAME <br /> APPgO%.DV <br /> 11I DEPTH <br /> GROUT BEAL PUMPED: Ely. ❑He CONCRETE PEDESTAL BY DRILLFR:❑Yw ON. S <br /> LOCKING CHESTER BOX/STOVE RPE <br /> PROPOBED CONSMUCTIONIDNLUNO METHOD: MUD ROTAgV5 <br /> AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THEWUR <br /> ORC WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CEWIFIEB THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL HOT EMPLOY MRSONe SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -.M CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T7' ANT MUST CALL 114 HOURS IN ADVANCE FOR ALL REQUIRED INSRECTIONS AT 111001 WAaS11. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blymd x M <br /> Title <br /> Data 1 'L3 -/ <br /> PLOT FLAN IDI.In Spalel Scale 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. l LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> I. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WRHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> Slt,c tk a I �P rr$yc_�� _ <br /> T'rAa9'i!NL`'N <br /> FEB 8 199r <br /> SAN✓UH �Lv-L, <br /> ...__ CICHEAL-r <br /> NVlRONMFnrr�, <br /> IL <br /> / DEPARTMENT USE ONLY /f(o <br /> Application Aecal BY Date ` `� Mw <br /> Glom Impeptlon BY Date Pump Impectlon BY Data <br /> Deatructlen Impwtlen 81 Data <br /> C.ccn,s : <br /> ACCOUNTING ONLY 7 AWI FACE <br /> PE CODES FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BY DATE PFRMITISERVICE REQUEST NUMBER INVOICE <br /> 3�D I OLI "0 So <br />