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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SER,-S <br /> i ENVIRONMENTAL HEALTH DIVISION <br /> ✓ P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TTblketel <br /> APPLICATION IS HERE BY MADE TO THE RAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SM <br /> JOAQUIN COUNTY DEVELOPMENT TITLES.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADURESSMA APNN# I `e)C� EU,,,j'CH d, CITU e- PARCEL SIZE/API [� Y� <br /> C is <br /> OWNER'S NAME ^A C/(•✓L ADDRESS /' `, �/J PHONE <br /> CONTRACTOR /�t1 7El l�ItiS A0011E66 //% //YYl' ��EJl?16 <br /> J <br /> SUB CONTRACTOR ADORERS UCO PHONE O <br /> TYPE OF WEUJNMP:VOaLNEW WELL ❑ PEPLACEMENT WELL ❑ MONITORING WELL O ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS ONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> ❑Naw❑Royal, H.P. DEPTH NMP SET-FT. FIRST WATER LEVEL D <br /> TYPE OF MMPI <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL O ❑ SOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED UBE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ♦' A <br /> 11INDUSTRIAL [IOPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> J� D <br /> 11DOMESTIC/PRIVATE 'GRAVEL PACK/SIZE TYPE OF CASING/STEELA Cj DIA.OF WELL CASINO SLE • D <br /> ❑ N6UC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATIONR <br /> cc <br /> �.IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROVE BRAND NAME I O E <br /> ❑ MONITORING— / /� (� GROUT SEAL NMPED4 Ys ❑ . <br /> No CONCRETE PEDESTAL BY DRILLER:❑Yu'. Bye S <br /> APPROX.DE H D-�YC�l�r/" �j/j� LOCKING CHESTER BOX/STOVE PIPE 5 <br /> PROPOSED CONSTAUCTIONIDWLUNO 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 BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AN; <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 WOW FOR MMICI <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU&CONTRACTING SIGNATURE CERTIFIE <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IR ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O <br /> CALIFORNIA.- THE APPLICANT MUST CALL ZA NO <br /> (�Wf IN ADVANCE FOR ALL REQUIRED I KCM"AT 12") tm A23. COMPLETE DRAWAT LOWER AREA FRONDED. <br /> t J�j�7n, <br /> SIpm6 x 1 IN�LL'tiP.E."E.'r Tltla 1-L' Nev, <br /> PLOT PLAN IDre«to Sealal Goal. •to <br /> I. NAMES OF STREETS OR MADE NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <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 PROPERTY OR ADJOINING PIbPLRTY. <br /> •5� tck3 �J <br /> Q-- �' - -O MAI; <br /> UL +icAl IN <br /> , dVlC.t;:- <br /> 1 kI <br /> DEPARTMENT USE ONLY <br /> Application Auapttl BY q V Dtls Arca <br /> Gann Impaction y Date91,0 �RSnp Impectlon By Data <br /> Dutmctlen Inspection 6raa��11((TT ''II--•• „,�,IY / �/1 Data <br /> Comment•: VV'VN a"VW IVVI /4 \STI/ <br /> ACCOUNTINO ONLY: AID# FAC# <br /> PE CODES iJYJRPO AMOUNT REMITTED 1, CHECK ASH RECEIVED BY DATE PElikul EWICB 7 NUMBER INVOICE <br /> I ISO 1 ,5 d1.f/7• 1I'1 �0�10 <br />