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APPLICATION FOR WELLJPUMP PERMIT <br /> 0 SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N. SAN JOAGUIN ST.,STOCKTON,CA 95201.388 <br /> (209)488-3420 <br /> NOWREFUNDAUE PERMIT EXPIRES 1 YEAR FRDM DATE ISSUED <br /> rl IComplat/In TriI;1 l <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANI INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE%COMPLIANCE WTTH SAN _ <br /> JO AOUIN COUNTY DEVELOPMENT TITLE,CCH-APTERI 9�I T}S.3 AANND�TW STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIDRaA�PPI/ VC,�T , CITY a�U PARCEL STZEIAPNN _ <br /> 1 ,,r ��� <br /> t YYV <br /> - OWNER'S NAME � ADDRESS��{[ffE`//] <br /> CONTRACTOR 4, ADORE.._ - V!".� �� LICI E <br /> L( SUB CONTRACTORNZA - ADDRESS LIC• PRONE/ <br /> � I <br /> TYPE OF WELLIPUMP: ❑NEW WELL ❑REPLACEMENT WELL Cl MONITORING WELL aI❑ry OTHER <br /> ❑INSTALLATION �LYELL jSYSTEM REPAIR ❑CROSSCONNECT REPAIR I..I VAPOR EXTRACTION WELLR ✓ <br /> 1 _ ❑Naw CJ Repair H.P. 1 DEPTH PUMP SET�FT. FIRST WATER LEVEL /� O <br /> RV FpIIMp] T- ' <br /> ❑OUT-OF-SERVICE WELL GEOPHYSICAL WELL I ❑ 6014 BORING g <br /> ❑DESTRUC-NON: <br /> INTENDER USE TYPE OF WELL CON6TRVCTION SPECIFICATION! A i <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DfA.OF CONDUCTOR CASING D <br /> �OMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEEVPVC DIA.OF WELL CASING D <br /> ❑ PUBUCIMVNICIPAL ❑CRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> 1 ❑ IRRIGATIONIAG ❑OTHER GROUT 5EAL INSTALLED BY GROUT BRAND NAME F <br /> L� ❑ MONITORING GROUT SEAL PUMPED:❑Yr ❑Na CONCRETE PEDESTAL 6Y DRILLER:❑Yw [IN. S r <br />{EfF JFF APPROX.DEPTH LOCKING CHESTER BOXISTOVE RPE S <br /> pRAposEp CoNaTRUCT1oNmmuma METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I <br /> I HEREBY CERTIFY THAT I RAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES-STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN UOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE wO1X FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSCNS SUBJECT TO WORKMAN'a COMPENSATION LAWS OF CALIFORNI CONTRACTDR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLO G; I CERTIFY THAT IN TNF PERFORMANCE OF 7HE VJOPK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY :WING <br /> TO WORKMAN'/',CI "ll LAW,OF <br /> _E CAl1FOPNIA THE APPUCA+JSJAYa7 CALL E4 HOURB IN <br /> ADVANCE POq Ali RE9UTAE0 ECTIyON/AT i2OS1 ASS�'123, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> r--�. 61gned Kti� Tllla (�� Gate <br />` . SLAT PLAN tD—to Suiel Sola -to <br /> 1 1. NAMES CF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM OR PROPOSED <br /> 2.OUTUNE OF THE PROPERTY,GIVING DIMEN61ONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE T90PERTY CA ADJOINING PROPERTY. <br /> .... .. ...;. .... .o.. .. ...o. ._.. .. <br /> a < 1�'.. <br /> '-zr <br /> v V 9 <br /> s '. „{..... ..... <br /> y <br /> . .. <br /> ...a <br /> F1 .;.. <br />{ 1 <br /> ..... . <br /> Yk <br /> I I-I J C-1 I Y I <br /> L <br /> 1 . ra <br /> fr._,.. t RLI <br /> DEPARTMENT UaB ONLY I ' <br /> Applica!{an Accepted Bp Olt. l Z Arae <br /> Groat B —P I-P-'l-BY_ - l I�./✓1-t..c.�-ray D.la �S-'/' ! <br /> De.lr�ct{ort Impeotlon By OateF] <br /> 1) <br /> Comma'On; <br /> ACCOU....ONLl: AIOI FACa <br />/ l PE CODES FEE INFO AMOUNT REMITTED CHEC fCASH RECOVER BY DATE PERMITISERVICE AEOUE2T NUMBER INVOICE <br />