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I ' <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> .—SAN JOAQUIN COUNTY PUBLIC HEALTH SERV11.fS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,904 EAST WEBER AVENUE.STOCKTON.CA 85201388 <br /> (2091488-3420 <br /> NON-REFUNDABLE PERMIT E)fPIRES 1 YEAR FROM DATE ISSUED <br /> 4.L APPLICATION R HERE BY MADE TO THE SAN JOAQUIN COUNTY POq A IRiRM1T TO CONSTRUlete CT <br /> OF <br /> Triplicate) ' <br /> JOAOUIN COUNTY DEVELOFMEM TALE,CHAPTER 9.1115.3 AND THE STANDARDS OF eAN JOAOU O INSTALOUNTY THE <br /> HEIO OWHEADE CRIBED.THIS APPUCATION EN VMO ENTAL S EA DE IN DMSON COMPLIANCE WITH SAN <br /> Joe ADORFSSMR APNA 1 I 1 F ��.I �, '_y n^kSEMMESi t. �,,A <br /> (•;I.1 „` .' \.n, ^� ;RT'F PARCEL MZEJAPHI 1 1^� <br /> OWNER'S NAME L ` 1 r �{ -/ �E <br /> �^ A AC'MRS4 \ i( (��Ln .\ JI.V• PHONE E 1, I- <br /> CONTRACTo v t Ji r �- '>1l" !U+ I.v i A� _ <br /> r � AooaESs �i.•nl�' ?'�Tt�, ucP N\F,(�1 E+aNEF��Z-Zn 21 <br /> 1 Sue CONTRACTOR R ' R^•R� <br /> C lr Vit Av F.e •.L 1. <br /> ADDRESS t...'1! 'It+']•I•. LK:J <br /> "OF WEW JAM ❑NEW WELL ❑REMCEMEM WELL ❑MONITORING WELL E ❑OTHER <br /> 7ti• ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CRo8$-CONNECT REPAM <br /> ❑VAPOR EKTRACTON WELL <br /> J <br /> N•w❑�4 H-P' DEPTH PUMP SET�-FT. <br /> (TYPE OF PUMP) 11 FIRST�fIATFR LEVEL O <br /> ❑OUT-OSERE WELL ❑GEOPHYSICAL WELL f Ir[alr/IOP_5O�IO <br /> DESTRUCTION: FVO <br /> f <br /> +� INTENDED VEE TYPE OF WELL CONfTRUCTION{PECIgCAiION{ <br /> ❑RMU'TRAL 11OPEN BOTTOM A <br /> ❑ <br /> DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO DOME$TIC/P[VATE ❑GRAVEL PACKieRE D <br /> TYPE OF CASINOMTEEL/PVC OU.OF WELL CASINO <br /> ElPURlICA/VNICAAI 11 DRIVEN O <br /> DEPTH OF GROUT SEAL SPECIFICATION <br /> 1"'• ❑RWGATIONIAG ❑ GROUT R <br /> OI/T SEAL INSTALLED SY GROUT BRAND NAME <br /> AFRO K.DOTH <br /> ❑MONITOPTH GROUT BEAL PUMPED:C]Y_ 11 N,. CONCRETE R <br /> s E <br /> FEDEAL BY DIILLER❑Y. 13u. •S <br /> LOCKING CHESTER SoKFSTOVE RPE <br /> PROPOSED CONSTRIMTION/DIIWNO METHOD:MUD ROTARY00% f, S <br /> AIR ROTAM AIOERs CABLE OTHER r✓A �. <br /> {� I HERFRY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOWK WILL SE DONE IN ACCORDANCE MTN RAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULE$AND <br /> RFGULATIONR OF THE SAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> I THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'f COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'$HIRING OR RUS-CONTRACTING RIONATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I RHALL EMPLOY PERSONS SUBJECT TO WORKMANY COMPDIMTON LAWS OF <br /> CAUFORMA.' T/}[A✓�UCANT MUST CALL 24 IW W 1M ADVANCE FOR ALL REOUNIFD I f►SCTpNf T 170514{5-1.1f.COMPLETE pRAWIIG AT LOWER AREA PROVIDED. i <br /> el rrd k Thl. 1 F•n (\,P/1 l T I n <br /> o.I <br /> ROT RAN IMw 1,8e 1 Sed• 1 <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DIRPOSAL SYSTEM OR PROPOSED <br /> Z.OUTUNE OF THE PIIOP�RrY,GIVING DIMENSIONS AND NORTH DIRECTION. <br /> G.(AWNSKINED OUTUMF8 AND LOCATION OF ALL EXISTING AND PKIPOBED EXPANSION OF SEWAGE TMNRDISPOSAL *OF ON <br /> - STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALK$, S.LOCATOR OF WELLS WITMN RADIVE PE ONE HUNDRED FIFTY FT. <br /> �M ON THE PROPERTY OR AOJORONG PROPERTY. <br /> . <br /> v €.. <br /> I <br /> s.. ......t... <br /> V. <br /> i <br /> I <br /> M I <br /> �+ �'/^j 1 t /7 /�, ,, DEPMTMBIUSE O <br /> f' lllr <br /> APNbAIIsn A••.fl•d Br1! 1�/'l1'/— 11... �r.,D•I•_ I r/ �r <br /> G•M In•Peetl•n er On• Puns In•P••S•n By DH• <br /> D•NINCIIM A'Is•elen <br /> By I <br /> �i DH{ I <br /> CammE•Hc I . <br /> I <br /> 1, ACCOVNTINO ONLY: AIDE PACS <br /> t <br /> P[CODER FEE INFO AMOUNT RFANTTED CHECK/MASH RSCBVED■r DAT[ PERMT!{FRVOt 11EOI/E{T Nl1MS61 INVOICE C <br /> 14 3 c,,r,, ^, D10 <br /> i <br />