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f � - ; '--- -' --�-=-w«--•"ter------. <br /> J <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 0 YEAR FROM DATE ISSUED <br /> {CompM(s IR TrIplkBts) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMA INSTALL THE WOM DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE�S,TTA�NDARDS OF DAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDAEBSKIR APNf 1 �/ l(r� CITY PARCEL RIZEIAPNf <br /> OWNER'S NAME-_ /yy�/ p{�r/���-� /�� J.�/G'.l� ADDRESS 3 /. ,, ��, - . PHONE A' ��,;,�"ihJE <br /> f� CONTRACTOR_ _-.JJ��� YJJ/y—? -(s1.�7//��_G./�-.� ADDREBS / G°fIICJC'.L%�",LICE �j PHONE 05! /��: �p�r� <br /> SUB CONTRACTORT�i%�� /y,���•«a Iy�,/��L i C?AOOREBS. ✓G- �iIJJ-fCN�/ PHONE f-s77.!7 /�fL <br /> TYPE OF WELLIPUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f ❑ OTHER <br /> C❑ INSTALLATKTN ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> _ ew❑Rppdr M.P.�� DEPTH PUMP 8ET/,�FT. j FIRST WATER LEVEL 7T— <br /> a <br /> TIYP£OF PUMPI <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL f - ❑ ROIL BORING <br /> 13 DESTRUCTION: 0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DLA.OF CONDUCTOR CASINO -••i- p <br /> DOMEStICA'FSVATE RAVEL PACKISIZE TYPE OF CASINGISTEEL47VC DIA,OF WELL CASING �y A <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION G�j(1_ R <br /> 11IRPIGATION/AA ❑OTHER GROUT SEAL INSTALLED BY /p/d!/p'/W�-41, GROUT SHAM NAME S.—... E <br /> CI MONITORING GROUT SEAL PUMPED« [IN. CONCRETE PEDESTAL BY DRILLER:❑y_.-Amo S <br /> APPROX.DEPTH gy/� LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONBTRVCTTONIDPoLUNG METHOD: MUD ROTARY A AIR ROTARY AUGER - CABLE, OTHER <br /> I ME'IEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CtFITMES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMFr IB ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'8 HIRING OR BUB-CONTRACTING;SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WOHWMAM'2 COMPENSATION LAWS OF <br /> CALIFORNIA," MV FIOURB IN ADVANCE FOR ALL REQUIRED INSFECTMNLLT 12001 -3423.M%mx }COMPLETE DRAWING At LOWER AREA PFbVIbE r, <br /> BlPrnd% '1✓4 Title �� 'V-� Da!• . <br /> PLOT PLAN(Drew to 904191 Scale •le <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. <. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,OMNO DWENVONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINF.B AND LOCATION OF ALL EXISTING AND PROPOSED - i, LOCATION OF WELLS WITHIN MdUB OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ...`,. <br /> us <br /> : o t <br /> : <br /> 1�I <br /> : <br /> r� n , <br /> ✓�� EPARTMEMT USE ONLY r � <br /> v � <br /> Application Ace"I d By //yyala C �? Ha4 <br /> U _ <br /> o'..lmpeetl9n BM InaPacllen BY 091• <br /> DMlrwllon InaPxllan BM / Dole I <br /> Cemrnenlc r '-` <br /> 45 <br /> :Ill <br /> -ACCOUNTING ONLY: AID/ FACT <br /> v <br /> PE CODES FEE INFO AMOUNT REMITTED OECK1171ASH RECEIVED BY DATE PERMITISERVICB REOVEST NUMBER INVOICE �. <br /> 3 54 050 5Dl �-( <br />