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SCANNED <br /> I APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> h 304 EAST WEBER AVENUE, STOCKTON, CA 95202 COPY <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED <br /> ICamplets in TripReatsi <br /> APPLICATION 19 HERE BY MADE TO 714E BAN JOAQUrN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK OffICRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITff SAN <br /> EI JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER!f` 9r1 <br /> -1111'S.3 AND THE 8TANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> mS J06 ADDRE8810R APNI V � <br /> ` CITY f PARCEL SIZE/APNN ✓a <br /> IP OWNER'S NAME <br /> .� Al... <br /> €�y <br /> ACONIRACTOR /f PHONE t�: 2—/7 <br /> SUB CONTRACTOR ADDRESS 26-3- 7 <br /> [, <br /> LK:I PIRQHE l <br /> ri <br /> !i TYPEDFS WELLIPUMP-. 9 <br /> riIELL El REPLACEMENT WELL ❑ MONriOWHO WELL N 13 OTHER INBTALLA710N 13 WELL SYSTEM REPAIR ❑ CR088-CONNECT REPAIR ❑ VAPOR EXTRACTIO14 WELL rT J <br /> (TYPE OF F'VMPI 11 Now 0 Retreir H.P. DEPTH PUMP SET PT, FIRST WATER LEVEL b <br /> `I <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOIL SORINO S <br /> !� ❑DESTRUCTION; - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �7 A <br /> ❑j'INDUSTRIAL f�❑p+OPEN 60T'TOM DIA.OF WELL EXCAVATION_ �nC 'f DIA.OF CONDUCTOR CASINO p <br /> � I`JGL L}QME8TICRRIVATE 1AVEL QACK181ZE TYPE OF CA$ITIO/eTEEUPVCy/.r�llG DIA.OF WELL CASrNO f <br /> ;i ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> © IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />` ❑ MONITORING �/ GROUT SEAL PUMPED: <- EI Na CONCRETE PEDESTAL BY RILLER:❑Yee Ne S <br /> APPROX.DEPTH LOCKING CHESTER 6QXMT0VE PIPE S <br /> .i PROPOSED CONSTRUCT}QTdb/Slt1H0 METHOD: MUD ROTARVAIR ROTARY. AUGER CABLE OTHER <br /> !I <br /> 1 HE9EBY CERTIFY THAT I HAVE PREPARED T14I9 APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> i REGULATIONS OF THE SAN JOAOUiN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH <br /> THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION TAWS OF CALIFORNIA,- CONTRACTOR'S Mm"a OR BU64CONTRACTMK3 SIGNATURE CERTIFIES <br /> THE FOLLOWING; 'I CERTIFY THAT IN TI4E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' INEAPPLICANT MUST CALL.24 HOURS/N ADVANCE FOR ALL R@GUMED tMspBCT10NS AT I"014q-f$22, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> $I$ 1 <br /> �yJ n <br /> nad X This �L/Y ,,..Det <br /> . - PLOT RAN 1Drew to Sadel Sade •to •� <br /> NAMES OF STREET@ OR ROAOS NEAREST TO OR BOUNDING THE PROPERTY 4. LOCATION OF HOUSE SEWAGE bispo AL SYSTEM OR p"OPOSEO `- <br /> 2. OUTLINE OF THE FQ+OPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 2- INMEN810HEp bU7LMIFe AND tOCAT1OM OF ALL EXISTING ANb PROPOSED - a;"LOCATK)N OF WELL9-WRHIN RADIUS OF ONE HUNDRED FIFTY FT, �+ <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOSr DRIVEWAYS;AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY, <br /> 130 <br /> r <br /> li .. <br /> { <br /> 1 y <br /> - b ENS ... <br /> IF ptnWT <br /> °g: <br /> II : <br /> ;I <br /> PuBt <br /> Al f�i <br /> cr <br /> I <br /> DEPARTMENT USE ONLY �7 <br /> APPIkellen A"ooled BY {I�(f I L <br /> IF bete <br /> ij O—A tn.peatlen BY <br /> Ste p 1mPeetlen By <br /> Ei Dote <br /> DnelnKUen rrwpea BY Dole <br /> CemmenH; 94 <br /> 22l <br /> I� I <br /> E <br /> I ACCOUNTING ONLY; Alp/ FACT' <br /> ,i PE CODES FEE INFO .AMOUNT RFMIT7_ "ECK# ASH RECEWEO BY DATE P91MIt/5EIIVICE REQUEST NUMBER INVOICE <br /> I r <br /> loll <br /> r <br /> ai Pub Haalth Sam-Enviro,173(1197) <br />