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1- <br /> APPLICATION FOR WELLrPUMP PERMIT'' <br /> '+AN JOAQUIN COUNTY PUBLIC HEALTH SERIN <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P'O' <br /> 80X�8, MX EAST WEBER AVENUE, STOCKTON, C Ou{2091468.3420 J,e; C <br /> NQK•REFUNDABLE PERMIT EXPIRES 1 YEAR FR4R1 QATE 1SSUEQ & 7 P/ <br /> APPLIrJOAQUIN ON 18 HERE EL MADE TO THE SAN JOAOVIN COUNTY FOR A PERMIT TO CONST(camRUCTn Twiests)INSTALL THE WORK DESCRIBED.THIS APPLICATIONG ` / <br /> JOAOUIN COUNTY DEVELOPMENT TTMA <br /> LE RAFTER <br /> / 1IS,3 AND TdE.sTANDARD� SAN JOAOVIN COUNTY PUBLIC HEALTH BERVICEB,ENVIRONMENTAL HEALTH DIVISION. <br /> COMPLIANCE WTT11 SAN <br /> JOB ADDRESSOR APNN E� 1 ! YQ.- / <br /> OWNER'S NAME CITY ��- PARCEL 81ZE/APTI# <br /> CONTRACTOR t. ��'r�'/ry-�`� �iI (� <br /> Y� W P e- it PHONE# cT G. .. <br /> ADDRESS �G ['��'� t, <br /> SUB CONTRACTOR LICK--,PHONE N <br /> ADDRESS" <br /> TYPE OF WELL/PUMP,' ❑ NEW WELL UCN--- � PHONE s��_ <br /> ❑ REPLACEMENT WELL ❑ MONITORING WELL N�� <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ OTHER <br /> ❑New❑ CROSS-CONNECT REPAIR <br /> (TYPEITYPE D��— Rep°Ir H.P. ❑ VAPOR EXTRACTION WELL# <br /> MP) ��. bEFTIi PUMP 8ET F'T. <br /> FIRST WATER LEVEL <br /> GOUT-OF-SERVICE WELL C1 GEOPHYSICAL WELL Nom` O <br /> ❑DESTRUCTION: ❑ BOIL BORING <br /> B <br /> INTENDED VSE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑OPCON6tgUC710N SPECIFICATIONS <br /> EN BOTTOM _I <br /> ❑ DOMESTiCIPFUVATE 11ORAVFJ_PACK/81-7tMA.OF WELL EXCAVATION E DIA,OF CONDUCTOR CARINA A <br /> IJ TYPE or CA81NG/STEEUI'VC D <br /> 1'UBLICIMUNICIPAL ❑DRIVEN DIA.OF WELL CASING <br /> ❑ IRRIGATION/AG DEPTH OF GROUT BEAL O <br /> ❑OTHER SPECIFICATION + <br /> ❑ MONITORING GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> APPROX.II GROUT GROUT SEAL PUMPED: ❑Yee No CONCRETE PEDESTAL BY pRILLER;❑Y*e [IN. <br /> S <br /> PROPOSED CONSTRUCTIONIORILUNG M <br /> LOCKING CHESTER BOX/STOVE MPE � <br /> ETHOD: MUD ROTARY <br /> I AIR ROTARY S <br /> — `AUGER��CAALEOTHER <br /> HE4EBY CERTIFY THAT 1 HAVE PRfPARfO THIS A <br /> REOULATIONB OF THE SAN JOAOUIN COUNTY. I'PLICATION ANO THAT THE WOI�(yyrU,eE DONE IN ACCORDANCE WITH BAH JOAOVIN COVNTY O - <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOgKMIAN'S COMPENSAT76N LAWS OF CALIFORNIA.- CONTRACTOR'S CER TOR•1 HIRING OR SVB�pNTRACTING HE VM r <br /> HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;•1 CERTIFY THAT IN THE PERFORMANCE OF THE WO <br /> CH <br /> RDINANCEB,STATE LAWS,AND RULES AND <br /> THE FOLLOWING; •1 CERTIFY THAT IN THE PERFORMAIVCE.OF..THE W0nK FOR WHICH.THIS.PERMIT Ig ISBUED,.I.SHALL EMPLOY PERSON"SUBJECT TO 8"a-CONTRACTING <br /> N'i TNG SIGNATURE <br /> COMPENSATION LAWSFIK Fon IOF <br /> CAL.IFORNIA,• TR <br /> APPLICANT MUST CA =�HG URE CERTIFIES <br /> Uq N DVANCE FOR AIA REGLIIRED INO"W'IONS AT 120914@S-3422. COMPLETE DRAWING AT LOWER AREA N't <br /> Slpned X ` <br /> Title <br /> Dote <br /> 1. NAMES OF STREETS OR ROADS (� <br /> PLOT PLAN Oto Bcel*I Scals <br /> ADB NEARE8T 70 OR BOUNDING THE PROPERTY. I �tO <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 4• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOgEO <br /> STRUCTUR6. LOCATION ES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, EXPANSIONOF WELLS OF SEWAGE WITHIN <br /> RAIL SYSTEMS, <br /> DIUS OF ONHUNDRED FIFTY FI. <br /> Foe x195. . : <br /> ON THE PROPERTY OR ADJOINING PROPERTYE <br /> IN z <br /> J. <br /> PAYM ENT <br /> JUL;1 ;0 1997. <br /> SAN JOAQUIN(:(I I I`. <br /> PUBLIC HEAL SERVICES <br /> FNVIHCNMENFAL HEALTH DIVISION <br /> .............:....... <br /> DEPARTMENT USE ONLY <br /> Appllcetlen Accepted By C <br /> 6M° <br /> Are* <br /> Ole+rl Imp-.Jr"'ey - <br />. DeteR+mp lrnpecllen By f �� <br />_ beelnrollen Irnpeeflon Ry bale <br /> Comments: <br /> Dote <br />�� ACCOUNTING ONLY: AID# I <br /> i FAC# <br /> PE CODES FFE INFO AMOUNT REMITTED ''L`kECK /CASH RECEIVED BY <br /> DATE PERM I"6EAV10EREQUEST NL SER <br /> O INVOICE <br /> )Ira <br /> r � _ <br />