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APPLICATION FOR WELL/PUMP PERMIT" <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES /nD�/ <br />�\ ENVIRONMENTAL HEALTH DIVISION CJp� <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (GLmpM16 In TrfpRe6tf) <br /> APPI ICATION IR HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT 70 CONSTRUCT AND/OR INSTALL 714F WORK DESCRIBED.TIITS AM IC AT ION ISMADE IN COMPLIANCE WITII SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 S. AND THE STANDARDS OF RAN JOAOUIN COUNTY PUBLIC HEALTH SEnVICFO,ENVIRONMENTAL HEALTH DIVISION. <br /> r <br /> JOB ADDRESS/On APN1 CITY C PARK EL a1z FIAR1+1 <br /> OWNER'S NAM ADDRESS/'n�j�{{/ A ��. �pi PHONE/ 1�( <br /> CONTRACTOR O� its L7C ADORE BB P f/('JI[�'�""-t•` UC/��/L+IZ PHONE I ^^^--+/ <br /> SUB CONTRACTOR ADDRESS LICE PHONE/ <br /> TYPE OF WELLMUMP: ❑ NFW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL• ❑ OTHER <br /> ,9 INSTALLATION ❑ WELL SV87 EM REPAIR ❑ CROSSLONNF.C{TyRE�PAIR C1 VAPOR EXTRACTION WELL/ J <br /> ❑N.w 11RevellH.P. 3 DEPTH PUMP BET/✓UFT. FIRST WATER LEVEL O <br /> HYPE OF PVMPI <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CON6TRlK:TION fPECIFICAT10Nf A <br /> ❑ INOII6TRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> fieDO MESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING D <br /> ❑ PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL IN97ALLED BY GROUT BRAND NAME F <br /> ❑ MONITORING ice" GROUT SEAL PUMPED: ❑Y.. 1114. CONCRETE PEDESTAL SY DRILLER:Ely- ❑Ne S <br /> APPROX.DEPTH `' LOCKING C1IESTEn BOX/STOVE APE 5 <br /> PROPOSED CONS TALK 710 NIDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEgEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORSL WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> nEOULATIONS OF THE BAN JOAOVN COUNTY. HOME OWNER OR LICENSED AGENT'B SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH <br /> TMS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS"JECT TO WORKMAN'f COMPENSATION LAWS OF CALIFORNIA.- COr'TRACTOR'S HIRING OR SU"ONTRACTNG SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS RHIkJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> C AUFORNIA.' THE PUCANT MUST CALL 24 HOU"IN ADVANCE FOR ALL REGUIRED INS►QCTIONS AT ITOSI 4".3427. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 1>, X .�- TItI. P, Dote <br /> PILOT RAN Mv—le P-1.l Sa Ne 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SFWAOE D4RPO8AL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.OPJ*M DIMEN8ION8 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTNO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALXS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> c�RJL <br /> C�� per- ��,,,�• � <br /> OfPARTF4MT VpF ONLY <br /> t �U <br /> A"11-0—A--1p 4 B / ow. <br /> r <br /> Grout I—peetlon By Dole Pi—p In..—tbn By Dole <br /> Oeelnrelbn I—peclbn Br D.te <br /> CornmrMe: <br /> AC COUHTI 40 ONLY: AID1 FACT <br /> P:CODES FEE INFO AMOUNT REMITTED CHECK AH REC13VED BY DATE PERMIT/6FAVICE REOUEST NUMBER INVOICE <br />