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M M Nam = = M M <br /> l�:r�arf`��1��"`",y, , � S'"j;�n�..w-�,�.,..-.-..z...�...•....-.- � »- ... .-.» Y�,..� w� .. ... J;w,.t G�t tr �� ,., m..� a�s"v Tr <br /> 4 APPLICATION FOR WELLrPUMP PERMIT <br /> SAN JOAQUIN COUNTYPUBLICHEALTH SERVICES <br /> f� ENVIRONMENTAL HEALTH DIVISION <br /> P.O.,BOX SW 304 EAST WEBER AVENUE STOCKTON SCA 952(31388 <br /> (209) 468-3420 <br /> NON REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Trldl3enh) <br /> APPLICATION 18 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND16R INSTALL THE WORK DESCRIBED THIS APPLICATION 18 MADE IN COMPLIANCE WITH Si <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9 1116 3 AND THE STANDARD$OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION <br /> JOB ADORESSJOR APNf S l <br /> CITY y1 - 0_1'_1KL # —PARCELJ <br /> � fle 7 <br /> OWNERS NAME V w T rPHONE f . 22 <br /> CONTRACTOR ! Q AOB�DRES /Adilf)f iji Llc`ra , NE#]V-39917 <br /> SUBCONTRACTOR 'e w 1 ADDRESS 7' / �(� Swdc IONE <br /> y.,e < 1 `j- -fi: <br /> TYPE OF WELLIPUMP (3 NEW WELL ❑ REPLACEMENT WELL, ( ❑ MONITORING WEwe ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS•CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> ❑Naw❑Rapalr H P DEPTH PUMP BET FT FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> ❑ OUT•OFBERVICE WELL © GEOPHYSICAL WELL# BOIL BORING _ <br /> ❑1*9M)CTION <br /> INTENDED US Tyn OF.WEL,�,I CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION 2 DIA OF CONDUCTOR CASING ! <br /> ❑ DOMESTICIPICVATE ❑GRAVEL PACKl81ZE TYPE OF CASINOISTEEL4nM DIA OF WELL CASING <br /> i <br /> ❑ PUSLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION / <br /> ❑ 1IAG ❑OTHER GROUT SEAL INSTALLED BY r (,ORO{!T BRAND NAME_&410 <br /> s <br /> 4- MONITORING J1 — 1 GROUT SEAL PUMPED 13Y. ❑No CONCRETE PEDESTAL BY DRILLER ❑Y. []No <br /> +, _ P x DEPTH______ _- '{ LOCKING CHESTER BOXISTOW RPE <br /> PROPOSED CONSTRUCTIONMFMIMG METHOD MUD ROTARY AIR ROTARY AUGER CABLE <br /> OTHERAZ.4L /]S� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULE$AA <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY HOME OWNER OR LICENSED AGENT 8 SIGNATURE CERTIFIES THE FALLOWING -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIG <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF CALIFORNIA- CONTRACTOR 8 HIRING OR BUB-CONTRACTING SIONATURE CERT Irl <br /> THE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN a COMPENSATION LAWS C <br /> CAUFORNFA HE ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGURED INSPECTIONS AT 12t14I44/04422 COMPLETE DRAWING AT LOWER AREA PROVIDED <br /> $Ionad X i!fy1✓J f'> Y f 1 _ <br /> T1n. n r'f) G'L Date � 3 <br /> PLOT PLAN(Drew to Scale)Goals "to <br /> 1 NAMES OF STREETO OR ROADS NEAREST TO OR BOUNDING THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2 OUTLINE OF THE PROPERTY,GING DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS <br /> Z DIMENSIONED OUTLINF9 AND LOCATION OF ALL EXISTING AND PROPOSED B LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOB DRIVEWAYS,AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY <br /> o� <br /> , <br /> 5 ! <br /> t� <br /> C <br /> DEPARTMENT USE ONLY { <br /> Application Aaoepted BY I` /t TI`-C f/ �/___ --- _ Data <br /> Orout Inspection By ata Pump Inspection By Date <br /> l Y <br /> Daatructlon lnapsotlon By. Iw. <br /> 1 � f Date. - J <br /> CommeMa r. �7 u1-d rc4_ V 1 Fy,n rj <br /> , (ifi.. I m f ke /VI G h T A i'1 11, <br /> h0 70-9� I.y <br /> ACCOUNTING ONLY AID# <br /> PACO <br /> PE CODES EEE INFO AMOUNT REMITTED HEC ASH -11ECEIVED BY DATE PERMITJSERVICE REQUEST NUMBBI INVOICE <br />