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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201.388 <br /> (209)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Ctmpl.tt in Trgliettt) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE Wfr1T$AN�' <br /> 10 QUIN COUNTY DEVELOPMENT TTITLE.CHAPTER 8-1115.3 AND THE STANDDAAR�DrS OF SAN JOAQUIN COUNTY PLISUC HEALTH <br /> SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APNN /L�/I� Acnr�m nc� r"\U CITY Imo\l.y�,j�y1'�-.�IU1J PARCEL SIZE/APN/ `,p <br /> OWNER'S <br /> CONTRACTOR AME Of�S,CA�Y(L(1r)-E-/C��L�I���I KS��(��� ADDRESS I Co' '(]U 1 I��j"C-O VYT/LL�1���.yyPHHONEI 5 1 -191(e D <br /> Sl CCS{A M$2 SCI'_y ICZ ADDRESS 1 0vs(X(P L IDT�'LIC,(,*-- toy PHONE/ <br /> SUBCONTRACTOR �T ADORE86 LK/ PHONE <br /> TYPE OF WELUPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL/ ❑OTHER <br /> ❑INSTALLATION WELL SYSTEM REPAIR ❑CROSS{ONNECT REPAIR ❑VAPOR EXTRACTION WELLt J <br /> ❑N—11 ReP.lr H.P. r DEPTH PUMP SEr__FT. FIRST WATER LEVEL 0 <br /> (TYPE OF PUMP <br /> ❑OUTaFSERVICE WELL ❑GEOPHYSICAL WELL/ ❑ 601E BORING B <br /> ❑DESTRUCTION: <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> I'OOMESTIC/REVATE 13 GRAVEL PACx/SRE TYPE OF CASING/STEEUPVC DIA.OF WELL CASING D <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONITORING GROUT SEAL PUMPED:❑Yr ❑No CONCRETE PEDESTAL BY MLIFR:❑Y.. ON. S <br /> APPROx.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTION/DRILLING METHOD:MUD ROTARY AIR ROTARY AUGER CASUE OTHER <br /> 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOROANCE 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 WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA• APR1C MUST O Z4 UILL IN ADVANCE FOR ALL REOURED IMSPECTIONt AT{3081 48tJ47�.COMPLETE WING AT LOWER AREA PROVIDED. <br /> SISn.d xC e.1 .E�/t,r_`/LT/` c�ir/h no. 0L4/U is D.I. <br /> PLOT PUN ID„ to Sul.]Sul. 1'4 •to 1 l L/- <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR FIRDPOSED <br /> I-OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROP062D S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> e0.v►'1P0 � e <br /> w <br /> T - <br /> AUG 21'1998 <br /> EIWIRGNMENTA_ t-A_I}ryl','i�•nN <br /> DEPARTMENT OSE ONLY -- -_ —--- -7, <br /> G­ <br /> bdluUon Accytad eY mt. Z AI., 7 <br /> Grout In ,Q <br /> .p-0-BY D.te Pump 1m;—tion BY .b ?s /y <br /> Drt tIc I,rpctbn BY Z. <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE CODES FEE INFO AMOUNT REMITTED HEC ASH RECEIVED BY DATE ►97AIT/SERVICE REQUEST NUMBER INVOICE <br /> C <br />