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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> memplet$III TrIplkals) <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMITTO CONSTRUCT ANDMR INSTALL THE WORK DESCTUBEO.THIS APPLICATION 18 MADE IN COMPLIANCE VITT"SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE 1STAN AIDS Of <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISIIOO{N. <br /> JOB ADDRE887pR APNNY6/ CITV �'•-- te J`� PARCEL SIZEIAPN9 <br /> UNTNER'8 NAME !.• 3�f..I .}S / -Z''! ADDRESS "'" I ;/)E.. +�"�'+ PHONE I I//fes ry "��1/N <br /> R lr�lr •� - ! ADDREBB rY S V E C.�G //p , I <br /> CONTRACTO <br /> BUB CONTRACTOR 3 t7/ - �` 5;1 { ADDRESS. <br /> � Li{ �f7` IJCI "r PRONE 7 '� <br /> [ <br /> TYPE OF WELL -MP ®EW WELL ❑ REPLACEMENT WELL Q(MONrTONNO WELL 1 � ❑ OTHER <br /> © INSTALLATION © WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑New❑Repak H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL O <br /> (TYPE OF PIRMPI <br /> ❑ pVT-0F•BERVICE WELL ❑ GEOPHYSICAL WELL f El BOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF ELL UC <br /> _ CONSTRTION SPECIFICATIONS '4 <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION f r DIA.OF CONDUCTOR CASINO *' N If <br /> O <br /> ❑ DOMESTICIPRIVATf RAVEL PACKISIZE TYPE OF CASING/STEEL P 3f I�..�-- DIA.OF WELL CASINO • f U <br /> ❑ PUSLICIMUNICIPAL ❑ONVEIN DEPTH OF DROIT SEAL + 1---, <br /> SPECIFICATION ,y/AI <br /> y R <br /> ❑ imomimAQ ❑OTHER GROUT SEAL INSTALLED BY t re", OROUT BRAND NAME �(�! i /A X-•- E <br /> (j/, GROUT fin(s,/�. I GROUT SEAL PVMPEO.- ❑Yr Ne CONCRETE PEDESTAL SY DRILLER:❑Yw [IN. S <br /> APPROX.DEPTH /1 5 _ LOCKING CHESTER. O ISTOVE PI`PE� S <br /> PROPOIED co Fd-"PIG METHOD; MUD ROTARY AIR ROTARY AUGER V CABLE OTHER <br /> 1 HErtEBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK YNLL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REQULATKINS OF THE SAN JOAQUIN COVNTY, HOME OWNER OR LICENBEO AGENT'S SIGNATURE CERTIFIES THE FOLLOWING.-1 CERTIFY THAT IN THE PEW40FMANCE Of THE WORK FOR WHICH <br /> THIS PERMIT 08 ISSUED,1 814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CAUTORI IA.• CONTRACTOR'S HIRING OR SUB•CONTRACTM SIGNATURE CERTtMS <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR WHICH THIS PERMrt 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CA HOURS RI ADVANCE FOR ALL REQUIRED IN P TIONS AV t2oal 4q-?1x3. COMPLETE DRAVNNO AT LOWER AREA PROVIDED. 2 <br /> Blened X TIS■, !)�f/ Date 1— � <br /> PLOT PLAN(Drew to 800141 Scala 'le <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH IN TION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OU TLWFB AND LOCATION Of ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITRIIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES,INCLUDING COVERED"FAB SUCH AS PATIOS,DRIVEWAYS.AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> [ <br /> DVAATMENT USE ONLY / <br /> Applleatlen Aasepted 8, "14 � __ Oe4e f? - Mr •/ <br /> , k <br /> Oreut Inpection By Dote Pump Impaction Sy Date <br /> D"romtlen Impeetbn BY Dots <br /> ACCOUNTING ONLY: AID# FAcs <br /> PE CODES FEE INFO AMOUNT RE MTTED CHEC CUMASH RECEIVED BY DATE PERMITISERVICE REQUEST NUN66t INVOICE <br /> Pub Health Serv.-ERYiro.173(1197) <br />