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w <br /> ` s APPLICATION FOR WELL/PUMP 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 /> 11MEFUNOABU PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CampM16 16 TFipReSts) <br /> APPLICATION 18 IIERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT:AND/OR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MAGE IN COMPLIANCE WITII SAN <br /> JOAQUIN COUNTY DEVELOPMENT T/RLE cj4AFFER$-1115.3 AND TI}HEE'STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> 309 ADDRE88/OR APN# G /D/ I11I� L I'I V e— "._CITY L/-} �G PARCEL BIZFJAPHI <br /> bill D11 rdon GD(�.7 � 5valPHONES <br /> 7- <br /> OWNER'SNAMADDRESS <br /> CONTRACTOR n Go561c .30/ L lbrru`'Givts»+er� / , <br /> ---ucr 62 PHOHEILlG5���6'g15b <br /> �7 / I --,yl, n <br /> SUBCONTRACTOR C L O-��0 AbbREBB G�b �/�lLI LUN'�-'rI rG LICSCS775-214 9 PHONE! -z6q �o•�-97M <br /> TYPE OF WELUPUMP' ❑ NEW WELL ❑ REPLACEMENT WELL E MONTTORINO WELL F ❑ OTHER <br /> ❑ INSTAU.ATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL#' J <br /> ❑Naw❑Rapetr H-P. DEPTH PUMP WtiT FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMPI �f <br /> ❑ OUT-0F-SERVICE WELL GEOPHYSICAL WELL$_ - ❑ SOIL BORING H <br /> /� ) 1 �]/ Verbo.] Oit.`, ron, ora Duncan ?a <br /> ®"DEWrpucTroN; /T�7D�1 �1Ar15 �GfK��/ , __/ JI�V" ��"�rtl —�,_D�jl,rz. <br /> INTENDED USE TYPE OF WELL CONBTRUCTION SPECIFICATIONS <br /> A <br /> St-c�l _/l C. De I s , n w o'7p 1" <br /> ❑ immaTmAt ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CA61"11511EEUPVC DIA-OF WELL CASINO O <br /> ❑ PUBUCIMUMCIPAL ❑DRIVEN DEFTH OF GROUT SEAL SPECIFICATION R <br /> ❑-IRRMATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITOpmo GROUT SEAL PUMPED:,❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑Ne S <br /> APPROX.DEATH LOCKING CHESTER BOXISTOVE PIPE S <br /> PROPOSED comemUCTiamm L41NG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> �S <br /> 1 HE4EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN 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 WORM TOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERBOHO SUBJECT TO WORIGNAN'B COMPENSATION LAWS OF CAUPOR NIA.- CONTRACTOR-@ HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PE14FOFMANCE OF THE WORK FOR WHICH THIS PERMrT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORIOWAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE ANT MUST CALL 24 UM IN_ .ADVAIICE FOR BALL REQUIRED INSPECTIONS AT 12051 4*ea42s. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> l�13 as <br /> 04ned X Title � ,! !C f1 T �� - --Data ! _ <br /> PLOT RAN{Draw to Scwej Beale 'to <br /> 1. NAMED OF STREETS OR ROADS NEAREBT TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE @SWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2, OUTLINE OF THE PROPERTY,OWING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM@. <br /> 3. WMENIIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOBED ■. 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 /> -. - ... <br /> ja n GC1 a 1 �a <br /> . <br /> .. <br /> _ _ x <br /> DEPARTMENT USE ONLY _ <br /> Appllpatlen Aaoepted BY � Data Q <br /> � ` Arae � Il <br /> 0'"InapeeRlen By 1'AL'�,&AAI e^— Data Pu p Intpeellon BY Date <br /> FD"umtlen Immo tlon BY - Date <br /> co—ardc <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT RIMTTED CHECKRMARH -RECEIVED BY.. DATE PORM TISEAVICE REQUEST NUMBER INVOICE <br /> ? .DO 62,os it L6 SSS <br /> Pub He@@h SerY.-Emliro.173(1197) 3 <br />