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APPLICATION FOR WELL,/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (ComplEtE IB T►IpBkatel <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TIIIS APPLICATION IS MADE IN COMPLIANCE WRI/SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE`.CHAPTER 9-1 11 5.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. <br /> JOB ADDRESWOR AP/N/ � W� �J j��j t�v A`/t7 CI'TY J� --K tU�� f�L}I' PARCEL SIZE/APN/ [//�[ <br /> OWNER'8 NAME (�'� tB1,/L�,,Ij ,L^�' ADDRESS C V J/6 L L Y 7/ i t PF10NE R 7 Q /'"-5 73 <br /> CONTRACTOR � E-L-f A `��jL YK p S ADDf1E88 7 7 <br /> J _P D B D x. � � 1 UC/ �/�E'NONE I <br /> SVS CONTRACTOR ADDRESS UC/ PHONE I <br /> TYPE OF WELLIPVMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> C '/l <br /> 1:1 INSTALLATION [I WELL SY$TE-7M REPAIR 11 CROSS-CONNECT <br /> ,,(REEPAIR ❑ VAPOR EXTRACTION WELL/ / <br /> 12(I`� L ❑New -RepNr H.P.�Y L� DEPTH PUMP SET/ !T/FT. FIRST WATER LEVEL 112- <br /> (I <br /> YPE OF PUMP) <br /> /� ❑ OUT-0F-SERVICE WELL I ❑ GEOPHYSICAL WELL/ ❑ SOI.BORING S <br /> ❑Iit-6FAIJei1ON- IF <br /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> KDOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELIPVC DIA.OF WELL CASINO <br /> ❑ PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING r- r GROUT SEAL PUMPED: ❑Ver (IN. CONCRETE PEDESTAL BY DRILLER:❑Yw ❑No 5 <br /> APPROX.DEPTH /S LOCKING CHESTER BOX/STOVE PI`E 5 <br /> PROPOSED CONS TRUC TIOMMMI.LING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE-ERY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE M 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 CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 19 ISSUED,19HALL NOT EMPLOY PERSONS SUSJECT TO WORKMAN'S COMIOQMXT'tON LAWS OF CALIFORMA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWINO: 'I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH TRIM PERMFT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAt fORMA..rte_THE AAPPPPLICA_NT MVSTfGC�}AL�/2 ISIS IN ADVANCE FO/JR/A jLL1n1/1EGUMED IN TnGONS AT 1205)SSS-f4". COMPLETE DRAWING AT LOWER AREA PR7,DE <br /> DL. <br /> S�X l�V�l.1/1.�--�1+'� ' / ���'Y/ V�-M- TIHe�,f� Dtte 7 .1 <br /> PLOT PLAN MD—to S-1e1 Boele to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GrVM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNES AND LOCATION Of ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTTMN MONS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .. .. . ..... ...J .. ...,.. .. __. .... <br /> .. <br /> `r <br /> ` d <br /> SAN JOAQUIN.G;,,unllY I� <br /> VUBLIC HEAL-T"SEAV104 h <br /> NVIRONMENTAL HEAUTH.DlV*lU!l <br /> i7 CR i•sin A i -- <br />