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-01 <br /> APPLICATION FOR WELLIPUMP PERMIT ` <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)488-3420 f ILE COPY <br /> C, o t A-AREFUNDABIE PERMIT EXPIRES i YEAR FROM RATE ISSUED <br /> ICampbh Im TTIpBeatMl <br /> APPLICATIO 18 HERE BY MADE TO THE GAN JOAOUM COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTEAR 9-111115.3'AND TLHE11{STANDARDS OF GAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVII�RI�ONMENT L HEALTH DIVISION, <br /> JOB AOORE88/OR APHI_ {!�� (yrl�. ' `+l kI�S'fG q.. +` _ � t �J!{{1AP /�PARC�SI EIA <br /> hS ()FL Til:L�J CITY [� / J / f /�1I <br /> OWNER'S NAME 1 C ADDRESS \-o- L!(]X h f�Cf Ci `i'HOIVE 9911S-0-50 <br /> CONTRACTORI r ��I-yL _. ADDRESS LZ� g'.F I�YITL 5'f LIC/ PHONE <br /> PUN CONTRACTOR f 'r L til 1 (4 Il AooREG �+ _iV��101 Pt Llcr 1 6 PHONE PU4 e g <br /> TYFEOP WIR-U IMM ❑ NEW WELL ❑ REPJICEMENT WELL MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL R J <br /> ❑Hew❑Repek H.P. DEPTH PUMP SET F7, FIRST WATER LEVEL O <br /> 1TYN'E OF PUMPI <br /> ❑ OUT�OF-MVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED US PBD CP iTRVC 10 SP IFC IONS A <br /> ❑ INDUSTRIAL ❑OPEN SOTTOM DIA.OF WELL EXCAVATION I g DIA.OF CONDUCTOR CASINO p <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACKIMZE TYPE OF CAMNOISTEEUPVC iG DOA.OF WELL CASING <br /> O <br /> ❑ PUBLICANUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION 15(U R <br /> ❑ IMOATIONIAO ❑OTHER GROUT SEAL INSTALLED BY Lr. r l� GROUT BRAND NAME IIa /t <br /> MONITORING f� { GROUT SEAL PUMPED: Q Yr• He CONCRETE P£DEBTAL BY DRILLER.❑Yea Ne S <br /> APPROX.DEPTH JZ LOCKING CHESTER BOXMTOVE M�tL� 5 <br /> PROPOSED CONSTTRICTIONICRILLING METHOD: MUD ROTARY AIR ROTARY AUGER ABLE OTHER <br /> 1 HEMEBY CERTIFY THAT I HAVE FREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCE8,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE GAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WINK" <br /> THIS PERMIT ISIS tl,I SHALL NOT EMPLOY PERSON8 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALR'O#MBA.' COHTRACTOR'B HIRING OR SU"ONTRACTING SIGNATURE CERTIFMG <br /> THE FOLLOWI CERT TN T IN THE PERFORMANCE OF THE WORK FOR NAIICH THIS PERMIT IS I9"0.1 SHALL EMPLOY PERSONS IIUWECT TO WORIONAN'S COMPENSATION LAWS OF <br /> CAUFORMA.- T T LL 24 UOURS IN ADVANCE FOR ALL REOUME4d BPECTIONS AT M"l 4SSi422. COMPLETE DRAVNNO AT LOWER AREA PROVIDED. <br /> Slpnad x .� C U'y Tn1.� 11tl Date -___-- - <br /> PLOT RAN Prow to Gariel Seale •to , <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL �T�j 1 POSED <br /> 2. OUTLINE OF THE PROFERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSALS �V 1Lr, DD <br /> S. DIMENSIONED OVTLOS.6 AND LOCATION OF ALL EXISTMG AND PROPOSED. S. LOCATION OF WELLS WITHIN RAOfU FIFTY FT. <br /> STRUCTURES,INCLUDING COVETED AREAS SUCH A8 PATIR76,DRIVEWAYS,AND WALXe. ON THE PROPERTY OR ADOD1111NG <br /> ........... 6 2 <br /> 3rr 1Y <br /> C � OP"UIN SES sio <br /> ;.. . <br /> 6 <br /> j ..,,.�....,�;,Y..«,;»* a.-�+ 'w:_ , ,: - -I � nl ls+fYuaan.R,�isrr�rewr.�•� 4'�I'�R'v�•'�s�'Q?I+ .+7}yyg91�" - <br /> - ,. :... :.. i. .-,.., .; •:...,,�... '.. ,, .r ... _ ... ., 6tdetrl- ..M1 �a:�4iRi;u: <br /> Y <br /> - s"°" '_� •gri.r�,�"-,e.'�-.�rei---•cr-� T� '.ter.+:. �wre�-�i7a... _ - +-„w.�6. <br /> - !.. <br /> s <br /> r J ' <br /> APPneelten Aaeapled By- - t ' '�.�� Oete w Arr— -� - <br /> of”tmpeel%n#I Date WmP Inepeetlen By Dele <br /> Dee.nAHen Inspeetlan BY Data <br /> � V-'l(1 :---- <br /> ACCOUNTINO ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT R TTED X ASN RECEIVED SY DAT PERMITISERVICE REQUEST NUMSIER INVOICE <br />