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i <br /> ' 1 APPLICATION FOR WELLIPUMP PERMIT <br /> IF ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 300,445 N.SAN JOAQUIN ST,STOCKTON,CA 952013/0 <br /> f <br /> 12091 488.2420 <br /> NON-REFUNDABLE PERMIT EXPtICS,T YFAR FR01R RATE ISSRER <br /> ICQmpbu In TryBwul <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMM INSTALL THE WORK DESCRIBED.THIS APPUCATION IG MADE IN COMPLIANCE WITH GAN <br /> rte. JDAGUN COUNTY DEVELOPMENT TITLE,C1HH.AAPPPTTE)R 9-1115.3µ Try ANpARpB OF 6AN JOADYIN COUNT/PUSIIC ILEAL 1 SEflVICE3,ENYIPDNMENTAL HEALTH pMSN}N, <br /> L JOB ADDRESSOR APNr 1 / CITY �} PARCEL S¢HAPNA <br /> ll1Gh GWNCFVIN ADDRESS 1150-J1 prq E/ <br /> ~ CONTfU1CTOR OPE89 LJ LIC/ NEI <br /> SUBCONTRACTOR 1''1 ADM$$ UC. PHONE <br /> TYPE OF WELLIPUMP. ElNEW WELL ❑REPACEMENT WELL ❑MONITORING WEUL# ❑OTHER <br /> L{❑.1 INSTµL/,T10N ❑WELL SYSTEM REPAIR ❑CROSSCONNECT RRE�PNR ❑VAPOR EKTP CTION WE"8 J <br /> �� f 'NRTA Rep.h H.P. OEFf1f PUMP SET�LFT. FlRSf WATER LEVEL O <br /> R'VPE OF PJMPI `�\\ <br /> Cl OUT-OFBERVICE WELL ❑GEOPHYSICAL WELL I ❑ SOIL BORING B <br /> ❑OE9TRlICTION: <br /> j INTFIrom usS TYPE OF WELT. CONSTRUCTION SPECIFICATIONS A~—� <br /> �❑INWBTplAL E3 OPEN <br /> BOTTDM DIA.OF WELL EKCAYATION DIA.OF CONDUCTOR CASING Q <br /> J�,�DOMEGTICfRYVATE 13 GRAVEL GRAVEL PACKTYPE OF CAGINGISTEEUP/C DIA.OF WELL CASING <br /> I /❑PUSLICIMUSMIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION IQ v <br /> ❑IRPGATMNTAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> ❑MONrroma GROUT SEAL PUMPED:13 Y- ❑N. CONCRETE PEDESTAL BY DWLLFR:❑Y- ❑N. <br /> AP X.DEPTH LOCKING CHESTER BOKRLTOVE PIPE S <br /> PROPOSED CONETRUCTIONIMUING METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEPFBY CERTIFY THAT I HAVE PREPARED THIS APPLICATIONµD THAT TNEVJDRC Wltl,NE DYNE fN ACCORDANCE WITH BAN JOAGVIN COUNTY ORIXkµCES.STATE IJ1W8,µD AIRES ANO <br /> WGUTATIONS OFTHE BAN JOAGUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIONATUIIE CERTIFIES THE FOLLOWNG:'I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR YMIC1r1 <br /> THIS PERMITIS ISSUED,I MALL NOTEMPLOY POISONG SUB%ECT TO WORKMAN'&COMPETIBAOON LAWS OFCAUFORMA.-COMPACTOR-S HIRING ORSUBCONTMCTINO SIONATUHE CEATIFlFS r <br /> THE FOLLOWING: -I CERTIFY THAT IH THE PERFORMANCE OF THE VMF9(FOR WHICH THIS FENMrt IS ISSUED,r SHALL EMPLOY PERSONS SUWECTTO WORKMAN%COM1 PINSATIOH LAWS OF� <br /> CALIFOP.NIM'THF CANT MUST C 24 DAIS IN ADYAHC FOl1 ALL REGIARm IN FCTIOMS ATIEOB/SFM1].COMPLETE DRAWING AT LOWER APER PROM <br /> [r'''�1 ThN paH <br /> PLOT PLAN IDww to Su1eI SuE. <br /> I. <br /> NAMES OF STREETS OR ROADS NEAREST TO DR BOUNDING THE PROPERTY, a.LO ON OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OVTUN OPY71E PROPERTY,GANG dMENSbNG AND NORTH DIRECTION. E%PANBION OF 6EWAGE Dig SAL 6YSTETAIS <br /> NSIONED <br /> �.DIMEOVITINESµD LOCATION OF ALL EEISTNO AND FKOPG&m S.LOCATION OF mmus WrrHIN RAO=OF ONE HUNDRED FIFTY FT. <br /> SRIVCTUIIEG,INCLUDING COWS AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PFDPERTY OR ADJOINING PROPERTY, <br /> .. ... .... .o ..:.......... �.... ........,... .. .....�_. a .: 1`u�'' <br /> Y' <br /> e... ..,o .. ......, ..,... <br /> .. -� .. <br /> .. c. ... .... ... .. <br /> .. ...,.. _�.. �. i.,,. ..... ..... �J,yp yyyj( q��y <br /> - k�f4 C 3ifl�IIQI R` <br /> .. .. .,... <br /> =N4IRLJPJivtEM;T.aLnEgfTF;fllV.IS u <br /> 1 t nwARmmlr u&B oRLY <br /> LF A}gowuon A-pl.Br -paw A- y� ' <br /> c,e,rt 1r-U-Brons Puma Inrawan Br <br /> Z.h.P.rUen ar Dn. <br /> C.--t.: <br /> I <br /> I <br /> ACCOUNTNO ONLY: ANTI F.C. <br /> ffCOQFA <br /> FEE INFO AMOUNT REMITTED EC IC N RECEIVED BY GATE PFIOi1TISERNCE REGVEST MIMBDI INVOICE <br /> 3 S— fU C2'162 7 <br /> a <br />