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APPLICATION FOR WELUPUMP 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 /> ,a, S <br /> NOR-REFURORSLE PERMIT E%PIRE3 1 YEAR FROM UTE 133UEU <br /> (Complete In TFbRBBIB( - `L s�E.•yw'e'L� <br /> APPLICATION IB IRFE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMM INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> — JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8.11 T 8.G LSD THE STAADS OF SAN JOAOUIN COUNTY IM CnnHEAL H SERVIC EB,ENVIRONMENTAL HEALTH DMBION. <br /> JOB AODREONMA AA-f AN C l CITY W✓E.• IPLAMEL BIZEJAP1f �qO�) <br /> OWNFR'BNAME �/�y�L� f � AD01 P Q a""l ,I�,, 4 RHONE F7SPT/� -{(�P <br /> CONTRACTOR / I- v L HIE ADDRF[B J*I' /r O d UCF ' Z PHONE f�J 12'-fFJZ� <br /> BUS CONTRACTOR ADIMESS S L"/ PHONE I <br /> _ TYPE OF WEIVFIIMP: rw(---WELL ❑ REPLACEMEMT WELL ❑ MONITOFMW WELL S ❑ OTHER <br /> ❑ HNBTALLATpN ❑ WELL SYSTEM REPAIR ❑ CBOSSLONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑New❑HM.A H.P. DEPTH PIMP SET FT. FIRST WATER LEVEL O <br /> D YPf OF PIMPI <br /> — ❑ OUTOFSERVM:F WELL ❑ GEOPHYSICAL WELL F ❑ 801E BONNO / <br /> ❑OESTRUCI ION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> — ❑ INDUSTRIAL 11 <br /> MELOPEN BOTTOM DIA.OF WELL EXCAVATIONS DIA.OF CONDUCTOR CASINO O <br /> MESTICAW �� <br /> VATE 1 }CIOVEL PACKISIZf TYPE OF CARINOIOTEJPVC� DIA.OF WELL CASINO p <br /> ElPLUSUCIMUWMAL '�❑ORKN DEPTH OF GROUT BEAL SPECIFICATION A <br /> — ❑ IRRIOATIONIAO ❑OTHER GROUT BEAL INSTALLED BY GROUT RAJND NAME ✓�, F <br /> ❑ MONITORING �`,�F GROUT BEAL PUMPED: YM ❑NP CONCRETE PEDESTAL B NLLER[IYHwf J S <br /> APPROR.DEPTH 3Z;To Lf LOCKING CHESTER BOXISTOVE RPE ,5 <br /> PROPOSED CONSTIIIICDOR/ LUNO MUHOO: MUD MIAMI^AIR POTARY AUGER CABLE OTHER <br /> I Hf Rf RY CERTIFY THAT I HAVE PREPARED THIS APP ICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH BAN"AOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AHO <br /> REOULATIONS OF THE SAN"AWN COUNTY. HOME OWNER OR LICENSED AOENT'S SIONATURE C[RTNES THE FOLLON,NG:•1 CERTIFY THAT IN THE PERFORMANCE OF TIIE WORE FOR WHICH <br /> TIRO PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENMTION LAWS OF CALIFORNIA.- CONTRACTOR'S RIMING OR SUS<OHFRACTING IMMATURE CERTIFIES <br /> TNF FOLLOWING: -I CERTIFY THAT N111115 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.1 MALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"WOOF <br /> — CALIFORNIA• INE APPUCAMT MUST CALL A IEU118 IN ADVANCE FOR ALL ROWED NSIICAOM AT IMI 441 1. COMPETE DRAWING AT LOWER AREA MIDNOEO. <br /> eHP..f X V <br /> CIL_ <br /> r f l_W (i :Y nn.__ <br /> NOT PIAN Idw Is BRNMI".I. •Is <br /> _ 1. NAMES OF STREETS OR ROADS NEAREST TO OR MIINDORO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROIOSfD <br /> Z. OUTLINE OF THE RIOPERTY.OIVNO DIMENSIONS AHD NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 1. DIMENSIONED OIFNJI AND LOCATION OF ALL EXIS IOM AND PROPOSED S. LOCATOR OF WELLS WITHIN MONS OF ONE HUNVV,D FIFTY ST. <br /> STRUCTURES,NCLUDINIO COVERED AREAS SACH AS PATIOS.DRVIIWAVS.ANO WAL I ON THE PREPPY,'OR AD"INNG PRDPEIRY. <br /> t^ <br /> fir <br /> fo re— <br /> h <br /> PA NT <br /> BAN.JUAUUIN Cc.:� <br /> HUBUC HEALTH P <br /> _. . ENVIFIONMENTA' R'.�:,..�r... <br /> n r <br />