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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N.SAN JOAQUIN ST.,STOCKTON,CA 96201388 <br /> (209)4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED — <br /> ICFRIPAIM M Tdplk.dl <br /> BEFLUCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERM"TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPUCATWN IS MADE IN COMPLIANCE WRH SA' <br /> JOAQUIN COUNTY DEVELOPMENT TrtLE,CHAPTER 9-1(C115.3 AND THE STA DS F SAN JOAQUIN COUNTY EXILIC HEALTH SERVICE.,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDM..roR.1 Sire t R cm C(f - <br /> PARCEL 6RF/APNB <br /> OWNER'S NAME C ADDRESSq37 , L O t EI s <br /> PHONE I <br /> CONTRACTOR L gDOflE.6 11//C I LIC PIQNE I <br /> SUBCONTRACTOR AAE,,....'' ADDRESS L'.k P LIC/ .E IF <br /> _ TYPEOF WELU`VMP: ❑NEW WELL ❑ REPLA�MW ❑MONITORING WELL• ❑OTHER <br /> ❑INSTALLATION ,LG1 <br /> - X411111-SYSTEMA PAIR ❑CPA98{ONNECT REPAIR ❑VAPOREXTMR.01, E F J <br /> ❑N-13 H.P. .1.PUMP GET_Ff. FIRST WATER LEVEL <br /> "YPE OF PUMP �(T1✓IY4 burnO��C/'Eyn'W n ❑ OOHYSIC WLLI ❑ BOLBOWNGaF6ERNCEW <br /> ❑DSTRUCTNIN: Aje// qO <br /> INTENDED USE TYPE OF WIDE. CONSTRUCTION SPECIFICATIONS A <br /> 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ElDOMESTICMtlVATE 13 GRAVEL PACX/.RE TYPE OF CAGING/STEEL/PVC DIA.OF WELL CASING O <br /> ❑MS..MUNICIFAL 11 DRIVEN DEPTH OF GROUT SEAL IRREWICATION q <br /> ❑IRAIGATIONIAG ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONITOWNO OROIITSFA-EEMPEO:❑Ys QNe CONCPETFPDESTALBYDRILLPI❑YNI QNp S-J <br /> APPIOX.BER. LOCKING CHESTER BOXISTOVE RP y. L <br /> _ MOPOSED CONSEBMTIONIpOLLNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> T I HAW MPARED THIS AIRILATION AND THAT TXE WORI(WILL BE DONE IN ACCORDANCE YATX SAN JOANW COUNTY ORDINANCES,STATE LAW B,ANO RULES AND <br /> REGUUTIONS OF THE WN JOAQUIN C.111.NOME OWNER OR LICENSED AGENT'S OGNATLM CERTIFIES THE FOl1DN9NB:'1 CERTIFY THAT IN THE PERM <br /> RMANCE OF THE NOP(FOR WHICH <br /> THIS PERMIT IS ISSUED,I$HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFXFATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING Ofl 6 NECAM N C OF SIGNATURE R YAHIE6(' <br /> THE FOUJO... '.,ICE .. <br /> MAT IN THE PERFORMANCE OF THE WORE FOO W.ICN THIS PRM"1.IBBUEO.I SMALL EMPLOY.....UEJECT TO WORKMAN'S CO SIGMA TRE CERTIFIES <br /> OF <br /> CAIIWRNRA.' TN PFYCAN gWTC E4 NDURS IN ADVANCE IDR ALL REBURm INS TpXS I30BIM.JL38.CQMRETEDMWINO AT IOWFR AMA PYJVIDEO. <br /> IF�T/ <br /> slvR..KrpH_ .LC.( Of1pQ� DXe <br /> POT PAN IDI—1.&l aul.� _ <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSALSYSTEM O A EEMEW <br /> 2. OUtUNE OF THE PROPERTY.GIVNO OIMENEX NS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEM.. <br /> _A 3, DIMENSIONED OUTUNFS AND LOCATION OF All EXISTING AND PROPOSED B.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH A.PATIOS.DRIVEWAYS,AND WAIXS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> 0 <br /> fPile/ <br /> �o4nLL4�lalT <br /> B.. <br /> DEPARTMENT Uft ONLY 4-ny l ' <br /> Appliufpn <br /> ISS, <br /> A.-I-Rr <br /> c.vM ID.I.cuen Br D.I. Pwnp In.esKeD Br Dn. ,� <br /> OSHunwn Ir.psEb Br Da'. <br /> cemm <br /> ACCOUNTING ONLY: AIDE FACT <br /> P CDpFiEINFO M <br /> AOU.TRFMITTEO CNE AH RECEIVED BY GATE BERNSTMERVICE REQUEST NUMBER INVOICE <br /> :6 <br />