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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 96201388 <br /> (209) 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmp1818 in Triplicate) <br /> APPl1CATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS <br /> OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESSIOR ANI447104/r .�CE CITV/7 �ESGk 7SY�A PARCEL <br /> SIZE/APN# <br /> OWNER'SNAME ,/"'N . kCTf A/ ADDRESS J0'9' eo'Z 176 ],.�/�� .i{AI/(.� PK)NE s/ Q1- *'?S <br /> CONTRACTOR ��Y/A't-Ap o�oaons.✓ [J / ADDRESS!5 f� WMVC 14 Y UUSZZIZSPHONE/rG26ZZ-S�T: <br /> C"SD�CTOR (J ` to CA l �CJ ADDRESS UCI PHONE <br /> TYPE OF WELL MP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRONNG WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑N.❑R.Pol, N.P. DEPTH NMP SET FT. FIRST WATER LEVEL 0 <br /> TYPE OF NMP <br /> V11OUM1OFSENVICE WELL ❑ GEOPHYSICAL WELL I ❑ IL BORING <br /> DEBT <br /> ,UI /Jr[y47f/C,CL- 4&Al 44-/ s 4EA/-,--A& 1V&1-4 MN/- - <br /> INTENDED USE 'YPE OF W0.1 CONSTRUCTION SPECIFICATION{ A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM CIA.OF WELL EXCAVATION OR.OF CONDUCTOR CASING O <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACKI E TYPE OF CASINGWEEUPVC DIA.OF WELL CAJINP D <br /> ❑ NBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRWGATIONIAG ❑OTHER GROUT SEAL INSTALIED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑No CONCRETE PEDESTAL BY DRILLER:❑Yr []No 5 <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PPE 5 <br /> PROPOSED CONSTRUCTIONRINWNG METHOD: MUD ROTARY AIR ROTARY AUMR CARIE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATmN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND PULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER 09 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT I6166UED.1 HALL NOT EMPLOY PERSON OBJECT TO WORKMAN-4 COMMSATON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: I RII THAT IN THE PERIM E OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN".COMPENSATION LAWS OF <br /> CALIFORNIA.- T11E 1 T C IM AO ALL REOUMED ING114ECTI <br /> AT 12MI IaJ12S./C'OMPLETE ORAWINO AT LOWER AREA PROVI EO. <br /> 81'rwE x TIB. eg D,J [3'GT (�C'7.�(�C7 (57' D.I. 1712- <br /> P 3 94i <br /> J <br /> OT PUPA ROPER6W.1 6oW�'te SO <br /> RO <br /> 1. NAMES OF STREETS OR ADS NEAREST TO OR SOUNDING THE PROPERTY. 1. LOCATION OF HOUSE SEWAGE DISPOSAL BOR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE g6PO6AL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 5. LOCATION OF WELLS WTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> + / �///� Mw 5 <br /> a- <br /> Pit <br /> lJl �A <br /> fps <br /> r i <br /> OLIMTMLXT UEF ONLY <br /> G..ul IrrppuM B, D.0 Pumo ll,li—(ion BY D.Io <br /> o..In.cuon Iwo.�t�Jlo.n�Br ��I ��f Al�� Cc. <br /> ACCOUNTING ONLY: -IJ— AIDI FACT <br /> PE COD" FEE INFO yAOUNTFl CHECKIICASH RECEIVED BY DATE PERMITISFRVICE REQUEST NUMBER INVOICE <br /> Z NNo 2. o <br />