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APPLICATION FOR WELL[PLIMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ,r <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 95201.388 <br /> (209)468-3420 <br /> NOII,REFUNDAHLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDN��1�N <br /> I� ICompNh in TF-Iplicato �� ]',TrMS��/�{13���Fj�, 1Y <br /> APPLICATION 18 HERE RY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANCHOR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS ILTt3EYN(C�SMflj MICE 1YfTH SAN <br /> JOAGUIN COUNTY DEVELOPMENT TITLE,CHAPTER �D HE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL WEALTH DIVIGION, <br /> JOB ADORE65A]R APNf CITY'S) / (L PARCEL s ZEJASP.NF - <br /> OWNER'S NAME /` AOOPESS J 1 �- �PH'pNE7E1Z3&Py ADDRE �1P,I <br /> y{` SUB CONTRACTOR ADDRESS LIC, PHONE J <br /> TYPE OF WELL/PUMP: ❑NEN!WELL ❑REPLACEMENT WELL ❑MONITORTNO WELL 0 13 OTHER I <br /> INST�AyLL�ITION ❑WELL SYSTEM REPAIR ❑CRO SG-CCNNECT REPAIR L.1 VA1VR EXTRACTION WELL N <br /> 1 Q Nsy✓.J HepHr HJ` ( r7_ Df PTH PUMP SE'aFT, FIRST WATER LEVEL � O <br /> (TVP£OF PUMP} E---�I <br /> 0 OUT-OF-smviCE WELL ❑GEOPHYSICAL WELL 1 ❑ BOIL ROPING 8 <br /> ❑DEGTRUGTION: <br /> INTENCEO USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q <br /> 0 MOUSTRIAL 13 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> n�I bOMEGTHCMIIYATE {{Q'-11 GRAVEL PACKI512E TYPE OF CASINGISTEEVPVC DIA.OF WEU CASING Q <br /> 0 l <br /> LJ F-JELCMUNTCIPAL DRIVEN DEPTH OF GROUT SEAL SPECIFfCATION R <br /> ❑IRPIGATIONIAG ❑OTHER GAOUT SEAL INSTALLED BYFF--�t GROUT SRAND NAME 1F-TT E <br /> Q MONITORING GROUT SEAL WMF'EU:❑Yr ON, CONCRETE PEDESTAL BY DRILLER-❑Yr [IN. S C1 <br /> AFPROX.DEI LOCKING CHESTER BOXIGTGVF PIPE 3 - <br /> PROPOSED C0118TRUCTIONIMLLIN0 METHOD:MUD ROTARY AIR ROTARV AU111 CABLE OTHER Y <br /> I HENEBY CERTIFY THAT,HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQVIN COUNTY DFDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAgUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFCAMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS GUBJECTTO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CUNTRACTOR'8 HIRING OR OU"ONTRACTING SIGNATURE CERTIFIES II <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,r SHALE,EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIAN'THTE�A/P'P�l1CAN'T�{(N1�VS�T CA ALL-2`4 HOURS <br /> IN ADVANCE FOR AL1,REOUBIR INfP PGNB AT{IDYL 4EBJ13].COMPLETE DRAWING AT LOWER APIA PROVIDED. <br /> '' sly.wd X T LIc.CJ I 1\QJ�LT k�I 1 T, TIeIe__ -�•� y ILL_ f�2-9-9 <br />��■.�TFE PLOT PUN LD—to S-r•I SUI. •m <br /> I.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A.LOCATION OF HOUSE SEWAGE DMPOSAL SY8TEM OR PROPOSED <br /> 2.OVTUNE OF THE PROPERTY. <br /> GIVING DIMENSIONS AND NORTH DIRECTION. EXPAN8F0N OF SEWAGE OISPOOAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND J'RCPOSED S.LOCATION OF WELLS WITHIN RAD1V8 OF ONE HUNOPED FIFTY FT. <br /> STRUCTURES INCLUDING COVERED AREAS 611CH AS PATIOS,DRIVEWAYS,AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY <br /> - ... <br /> _..; .... <br /> II <br /> }I T <br /> 111 <br /> .. ...... i �t <br /> 11 St <br /> IL' j jj <br /> DEPARTMENT V.EEI <br /> APPIk•tlon AacNt•E BY D.t. ,• Z f <br /> Gta65lrnpectlan By D • Pvmp Impectlpn 8y A=lJ U•t. '� 20 I` <br /> Drntcthn Dspectlan BY D•1• <br /> Gemm..;n: I <br /> 1 <br /> ACCOUNTING ONtY; Albf FAC/ <br /> PECODU FEII AFAOUNT REMITTED cNECK/lOABH RECDVEO SY DATE PERMIT/1MV1 C�)E�REEQUEST NUMME{ INVOICE , <br /> O / <br />