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�OC <br /> APPLICATION FOR WELLJPUMP PERMIT j <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95282 <br /> (209)46&3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IC@mpl@a in TrlpRcatel <br /> APPLICATION 48 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL.THE WON(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1116.3 AND TNFBTANDAROB OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH I)MM 7N. J ._p <br /> JOB ADORESSIOR APNr CITY CLI.i�L PARCEL BIZFIAPH/ 7-L r <br /> r <br /> OWNER'S NAME r ADORES8)nA <br /> PFIONE r <br /> + , t Ll e <br /> CONTRACTOR L v I-L ( ADDRE6e uCr f ZT +ro <br /> ,PNE <br /> SUB CONTRACTOR ADDRESS LICE PHONE r <br /> TYPE OF WELLJPUMP 9NEW WELL 13 REPLACEMENT WELL ❑ MONITORING WELLR ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CRDOS-CONMECT REPAIR ❑ VAPOR EXTRA J <br /> ❑New❑P'w-k H.P. DEPTH PIMP BET FT. W O <br /> ITYPE OF PUMP) <br /> © DVT-0F•BERVICE WELL ❑ GEOPHYSICAL WELL r BOIL MN B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF W CONSTRUCTION SPECIFICATIONS A <br /> ❑ INUU8TRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> OMESTICIPNVATE ON`VEL PACKIBIZE TYPE OF CASINGIBTEEUPVC G DIA.OF WELL CASINO l� b <br /> ❑ PUBLICIMUNK:IPAL ❑DRIVEN DEPTH OF GROUT SEAL // BPECIFICATtON R <br /> ❑ rMCATIONIAG ❑OTHER GROUT SEAL INSTALLED BY 014a ITL! f 1'� ._ GROUT GRAM NAME E <br /> El MONITORING GROUT BEAL PUMPED-Ry. ❑Ne CONCRETE PEDESTAL BY BILLER:❑Yw Ne S <br /> Ar X.DEPTH LOCKING CHESTER BOXISTOVE RPE S <br /> PROPOSED COMSTRUCTIONMNLLiRG METHOD: MUD ROTARY,,,,,AIR ROTARY AUGER CABLE OTHER <br /> 1 HE4EBY 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 AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNty. HOME OWNER OR LICENSED AGENT'S BIOHATUM CERTIFIER THE FOLLOWING:'1 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 BU"ONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN TIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONA SUBJECT TO WOR%MAN'8 COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 NO ADVANCE FOR ALL REOUIR"INBPEC7bNS AT 120SI 4"-142!. COMPETE DRAIIINO AT LOWER AREA PROVIDED. <br /> 1 • <br /> SIM X_({ V Y V\ _ TIHa D-- <br /> PLO <br /> ae• <br /> PLOT PLAN(Mr to Seale)Se-ta 'to <br /> 1, NAME@ OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PSOPERrY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIePOBAL BYBTEMS. <br /> 3, DIMENSIONED tlUTLINF.8 AND LOCATION OF ALL EXISTING AND PROPOBED S. LOCATION OF WELLS WFTH1N RADIUS OF ONE HUNOREO FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,ONVEWAYS,AND WALK& ON THE PROPERTY OR ADJOINING PROPERTY. <br /> L l <br /> .......... <br /> 51 <br /> w <br /> : <br /> N� <br /> - ; <br /> - IV NUN <br /> i�VV)R0NMENfR1.,1i q'i TH p E <br /> O' S A <br /> — VEPMtMENT UB!ONLY <br /> Appliaaelnn Awepted Dale • <br /> O.a1M knpwtlen BY Dot P Irnpeetlen By Date <br /> Dedn�etbn Ir paelfen By Qate <br /> i <br /> CemmerNa• <br /> Del "19A <br /> zQ— <br /> ACCOUNTING ONLYr NDE FACE <br /> PE COOE@ FEE INFO AMOUNT REI4ATTED CHECK/ICA H RECEIVED @Y DATE PERMITIOERVICE REOUEBT NUMBER INVOICE <br /> y 3(� a 9 3 l�ol ss <br />