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APPLICATION FOR WELLIPUMP PERMI- <br /> U SAN JOAQUIN COUNTY PUBLIC HEALTH SEhwoES <br /> ENVIRONMENTAL HEALTH DIVISION YMENT <br /> 88, <br /> P.O. BOX 9 304 EAST WEBER AVENUE, STOCKTON, CA 9520 <br /> (209) 460-3420 EIVED <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER U k C 13 19,°5 <br /> (CompMh In Tripikata) pDSAN JCI. �UIfN OGpU9`NITY <br /> APPLICATION IS HERE BY MAGE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DEBCRIBECO.��TN r GRV�C <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 3-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICIiyER ����1�"(rl�""'_ WITH SAN <br /> ES <br /> DI ION. <br /> JOB ADDRESSXOR APNI J s G, ' . <br /> CITY @� �V yPARCEL <br /> ('�8112E/ G <br /> OWNER'S NAME _I �L-L1 Cl ADDRESS �Jw ! O Q((�.O-'ty �'I.�] "-PHONE 0 O 70 <br /> rF/ <br /> /�dNcowM4 R-V'+tLG-. ADDRESS ZUJ L..BH M L.t^ LIc,6 ITaI /' /PHONE! -3-074- <br /> p y �E COMMCTOR S M_. R � -y g 5� 12 C6 PHONE` <br /> '�IEA�,F—TYPE OF WELL/PUMP: ❑ NEW WELL ❑ RFMCEMENT WELL FKONRORINO WELL♦ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> (TYPE OF PUMP) <br /> 11Now❑Rep.1, H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL A SOIL BORING g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I( A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING�i O <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC J DIA.OF WELL CASINO L/t g <br /> ❑ PUBUC/MUNICIPAL ❑DRVEN DEPTH OF GROVE SEAL " S 1 SPECIFICATION g <br /> 11IRRIGATION/AG 11 OTHER GROUP SEAL INSTALLED BY ;-EJL^L J IQti GROUT BRAND NAME E <br /> VLMONITORNG I GROUT SEAL PUMPED: Vr I [IN. CONCRETE PEDESTAL BV DRILLER:Ely. ❑N. S <br /> APPROX.DMH OCKING CHESTERIO STOVE PPE S <br /> RIOPOSED CONSTRUCTION/ORLUNO METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CEIRIMES <br /> THE FOLLOWS G: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIG IS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPjJCANT MUST <br /> CALL 24 HOURS IN ADVANCE FOR ALL REQURm IN{ 110 T 12081 Ap3{ OMPLETE DRAVING AT LOWER Dort. <br /> A„� �� <br /> Sl'ood X M , `1�� Title `f_'MI11 <br /> JI 17.w 1 <br /> PLOT PIAN ID,.t.e.el.l Sulo 'to LV <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PIOPOSED <br /> 2. 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 WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTYORADJOINING PROPERTY. <br /> 3IS ( �� itr �oSr3 /V4TF <br /> t .l­.v <br /> o - p 6a- <br /> H� 4kNz. <br /> I7 Da <br /> L <br /> t H <br /> 4 DEPARTMENT USE ONLY <br /> 1111nn I/11 �^ /n <br /> Avvllutbn Accepted BY�JI/Y "C/1 L.1 LI beta , At. <br /> Grout ImPecOon BY Dot. Pump l.'ectlon BY Dot. <br /> Destruction Impaction Br M , -} <br /> C.mrr,enw P u,v go 6g'3 � 19.7 W't^ L{Lb T�c7wT-� "'�'J` c.� P✓'�7N- a-a <br /> ACCOUNTING ONLY: AIDS FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKI/CASH RECBVEO Y DATE PEMIT/SERVICE REQUEST NUMBER INVOICE <br /> O �� <br />