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APPLICATION FOR WELLIPUMP 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 /> �i \ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> icampNb M TripRoit6! <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOIHM COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRSIED.THIS APPLICATIOH IS MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPM HT LE.CHAPTER 9-1715.3 AND <br /> ©©THE STANDARDS OF SAN JO <br /> AOVIH COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH pM81pN. <br />` JOB ADDRESSIOR APNI 4-, CITY - {ti <br /> J PARCEL 812EIAPRN/ ,�+w'� <br /> �t PHONE/ <br /> OWNER'S NAME ADORE88 <br /> CONTRACTOR Al <br /> I PI ADOFRE88 UD NI,,--- -i�F-� <br /> SUS,CONTRACTOR <br /> ADDRESS LICE PHONE: <br /> TY Pj OF WELLIPUMP' t=]LATtOW <br /> ELL ❑ REPLACEMENT WELL CI MONITOIRINO WELL/ [3 OTHER <br /> ❑ WELL Y@TEM REPAIR ❑ CR099-CONNECT REPAIR ❑ VAPOR ExTRACTION WELL IF J <br /> o/,1 jvNwn❑IMp k H,P. _ DEPTH RUMP SET�FT. FIRST WATER LEVEL, l V - O <br /> ITYPE OF MPI ❑ OUT OF-SERVICE WELL ❑ 0£OP4tYSICAffLWE��LL/ ❑ SOIL SORFNO S <br /> Fi <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPf OF WELL CONSTRUCTION SPECIFICATIONS /��/ A <br /> r! ❑ DNDUS'TI8/1L ❑OPEN BOTTOMf DIA.OF WELL EkCAVATION Z� _ INA.OF CONDUCTOR CASING— I D <br /> . DOMESTICIPR IVATE ❑GRAVEL PACKMZIE TYPE OF CASINGISTEELTVC IrY DIA.OF WELL CASINO aa 0 <br /> 9 pUSLIGMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL <br /> SPECIFICATION 17` <br /> ❑ HIi1aOATIONIAO ❑OTHER GROUP SEAL INSTALLED BY OROIIt BRAND NAME / E <br /> ❑ MONITORING - GROUT SEAL PUMMO: VYa- ❑Na CONCRETE PEDESTAL BY MULLER Yr ❑Ne S <br /> APFRCx.OirTH � -_ LOCKING CHESTER GOk/BTOVE RPE S <br /> k FRMPOSED CORR6I7IUCTIONID18LLtNO HIETNOO. MVb ROTARY AIR ROTARY AUGER GABLE OTHER <br /> ` J 114E4EBY CERT1fY THAT I HAVE pWPARED TMS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH GAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RVLEB ANO <br /> REGULATIONS OF THE SAM JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SNGHATUIIE CERTIFIES THE FOLLOWING,'I CERTIFY THAT IN TRIE PERFORMANCE Of THE WORK FOR WMCH <br /> THIS PERMFT IS ISSUED,I SHALL NOT EMPLOY PERSONG SUBJECT TO WORIMAR'S COMPI NATION LAWS OF CAL.IFOMAA.' CONNTRACTOR'S MRIHO OR SUS-CONTRACTING SIGNATURE CERTIFIES <br /> r THE FOLLOWING: 'I CERTIFY THAT IN THIP PERFORMANCE OF THE WORK FOR WHICH THIS PERMFT 18 I@BVED,i @HALL EMPLOY PERSONS SUBJECT TO WORIIOMAN'S COMPJN6ATI N LAW9 OF <br /> !! CALIFORNIA.' T M T CALL 1 H,1/OURS IN ADVANCE FOR ALL REOUIRED INSFFC�TIONS AT 12061 Mq�42i• COMPLETE pRAWMId AT LOWER AREA Pr10V1 D. <br /> 919 <br /> SIp+M x •'�i Oats <br /> PLOT PLAN 1D-aw is 9add GeN� '1* <br /> 1 1. MIMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY- A. LOCATION OF HOUSE E DISPOWAGESAL <br /> DISPOSAL SYSTEM OR PROPOSED <br /> j 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE gBPOSAI SYSTEMS. <br /> 3. ONAENCIONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS VATWM RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURE@.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PRDFEATY. <br /> MEW <br /> N <br /> -la�T .919 <br /> ..� ] � Srin Jt�llc3l�lty C el r <br />