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APPLICATION FOR WELLIPUMP PERMIT <br /> u SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIM <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX SIM 304 EAST WEBER AVENUE, STOCKTON, CA 95201.986 <br /> (2091489-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete M TrIpReSto) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WRIT BAN <br /> JOAOUIN COUNTY MVELOPMENT TITLE,CHA`PTER e-1116.3 AND THE STANDARDS OF SAN JOAWIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESSron APIM �} 6 //O �<Y1xx0AJ I'VF• urs // �L• C�72, �5��,/�37` MACEL azETAM# (� <br /> OWNER'S NAME 4 H. d 2 AOORESS1%`dNlo7 SaHFJ <br /> -T .7— <br /> F.^I�i /r�ygpS�PHONEF <br /> COXETMCTOR S /O AJ o S.e/II(L'Q ADDRESS O �'�. CI lL O( PHONES <br /> 1 <br /> BUB CONTRACTOR ADDRESS / T e y, G. L C# PHONE 0 <br /> TYPE OF WELI/PJMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL F ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F I <br /> ❑Nw ErpeP , H.P. DEPTH PUMP BET&()FT. FIRST WATER LEM <br /> ITYRE OF FUM% <br /> ❑ OOT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING B <br /> ❑OESTRUCUON' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 6 <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CARING O <br /> ❑ DOMESTICRYOVATE ❑GRAVEL PACKMIZE TYPE OF CASINO/BTEELAPVC DIA.OF WELL CASINO D <br /> ❑ MWICMLINICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ <br /> IRRIGATION/AG ❑OTHER GROW BEAL INSTALLED BY GROW BRAND NAME F <br /> ❑ MONITORIIJG GROUT REAL PUMPED: ❑Ya ON. CONCRETE REMBTAL BY DWLLER:❑Va ❑Ne 5 7 <br /> APPROX.DEPTH LOCKINO CHESTER BOXAMOVE RPE h v <br /> PROPOSED CONSTRUCTIONI UJNO METHOD: MUD ROTARY Am ROTARY AUGER CABLE OTHER V <br /> C <br /> 1 WE BY CERTIFY 114AT I HAVE PREPARED THIS APF%JCATmN AND THAT THE WOM WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES ANO � <br /> REGULATIONS Of THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED ADEN -9 SIGNATURE CEREDIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORRMAWS COMPENSATION"We OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-COWMCTINO SIGNATURE CEMIHF8 <br /> THE FOLLOWING: 1 CAIFIIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIR PERMIT IB IBRUFD,1 SHALL EMPLOY PERSONS SUBJECT TO WORMAN'S COMPENSATION LAW$OF <br /> CALIFORNIA: T A/NT MOST CALL 24 <br /> 2A�N/O/f�R1•�IN ADVANCE FOR ALL REOURED INSPECTION&AATT1122MI A4J1]i. COMPLETE DRAWING AT LOWER AREA FRONDED. <br /> $IPnb X //.//G'I /�W/L/-f TIIIe `� '�' // '��— D•1• ��� FFA — • Y <br /> PLOT PLAN RN..Y 1.Be•1•I 8e•I• •to y <br /> I. NAMES OF STREETS OR WADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE GRIMM SYSTEM OR PROPOSED _ <br /> 2. OUTLINE OF THE KOKIRTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPOM SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PFX)MSM S. LOCATION OF WELLS WITHIN MDRIS OF ONE HUNDRED FIFTY rT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND VAMS. ON THE PROPERTY OR ADJOINING PPOKRTY. S <br /> J <br /> y i <br /> N� kit � �' 01✓ 4 <br /> I <br /> ti <br /> }� I b -THF, <br /> liTi' <br /> DEPARTMENT USE ONLY <br /> APW.a Ane Ie By C A N�/W� /✓� flet. <br /> /1/�`� Ma <br /> OrwA InnpalNn BryD.. PV me Impevtlen By (i/if//A/� //'S 3 Delo <br /> DaHnvllen Irnnxllan Rv DHe <br /> Dnmmae.: <br /> ACCOUNTING ONLY: MDR FACT <br /> PE CODES FEE INFO AMOUNT REn11TTED HEC ASII RECEIVED BY DATE PEIMITMFRVICB REOLIFST NUMBER INVOICE <br /> 4,2;1So kaloa h 1-3 9 D3 a3 <br /> Pub.Health Saw.-Enviro.173(3/96) <br />