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N,w/ APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, Box m 304 EAST WEBER AVENUE, STOCKTON, CA 95Q0J M <br /> (2091402-3420 <br /> RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM! DATE ISSUED <br /> al <br /> APPLICATION 19 THERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTtI <br /> A DMn INtSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMEE�NT TITTLE.CHAPTER 9-1116,3 AND THE S01 TA DARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,EHVIpONMENTA!HEALTH DIVISION. <br /> JOB ADDRESSIOR APNI.�p�Q O �� 4, _)1 _ �`- cITY 1.+0d <br /> y�QG�-,�� Q (]F / PARCEL SIZEIAPNI <br /> OWNER'S NAME �� R`Y.-7JCll JQ ADORERS D CrOW Y� T1 1. �a�O 3qn THrYIUY7 <br /> CONTRACTOR PHONE <br /> AtlbpEe6 1 UCI �Ia��O PHONE/7Q ��8�1�a, <br /> SUB CONTRACTOR �-Fn!1!.}�ti 1 I 9 S,�05 <br /> -ID'- <br /> ADDRESS �l+�f�J V r 1 l p}v{ LIC/`�..�PHONE <br /> it <br /> TYPE OF MLLIPUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ <br /> CROSS-CONNECT REPAIR ❑ OTHER <br /> ❑ VAPOR EXTRACTION WELL♦ J <br /> ©New 11Rep.l, M.P. DEPTH PUMP SET FT. <br /> ITYPE OF PUMP1 FIRST WATER LEVEL 0 <br /> ❑ <br /> �ESTRUCTIONOUT-OF-SERVICE WELL ❑ GEOPIYBICAL WELL/ r ❑ SOIL BORING 9 <br /> b : � �4U <br /> INTENDED USE TYPE OF WELL CONSTgVCT10N SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOMA <br /> DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACKl8IZE TYpt OF CAGINOISTEELIPVcD <br /> DIA,OF WELL CASINO D <br /> PUBLIC/MUNICIPAL ❑ORIVEN DEPTH OF GROUT SEA! <br /> ❑ IRRIGATI0N/AG 11 OTHER SPECIFICATION 9 <br /> GROUT SEAL INSTALLED BV GROUT BRAND NAME <br /> ❑ MONTORiHG E <br /> APPROX.DEPTH <br /> GROUT SEAL PUMPED: Ely. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yee []No 5 <br /> LOCKING CHESTER BOXISTOVE PPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOO: MUD ROTARYS <br /> AIR ROTARY AUGER CABLE OTHER <br /> 1 NE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUW 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 WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'!COMPENSATION LAWS OF <br /> CAUFO THE CANT MU CALL 24 HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001498-M22. COMPLLEET�E.�DAMNING,,AT LOWER AREA PROVIDED. <br /> k Tltls_ 1 m�n isi I YN !�F\\ I:�—y F�}"�'�Dote_ I.0-aa,-1. 7 <br /> PLOT PLAN(Drow to Bode)Salve •to 1�—F-7L�--. l+i l�—�- <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, <br /> 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4 LOCATION OF"OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2, DIMENSIONED OUTLINES AND LOCATION OF ALt EXISTING AND PROPOSEDEXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> INCLUDING CLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> .. ON THE PROPERTY OR ADJOIIM pRopERTy. <br /> r <br /> bmARTMENi USE ONLY +�� <br /> Applleotlen Aceeoled By <br /> a.,. Anse <br /> Grout impaction B40 <br /> Y note Pkrnp Inspection By <br /> Date <br /> De.trnellen Impecilen By <br /> Dole <br /> Cemmer.tr� � _ <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE TNPO AMOUNT REMITTED CHECKI/CASII RECEIVED SY DATE <br /> PERMITISERVICE REQUEST NUMBER INVOICE <br /> Pub.Health Serv.-Enviro.173(3196) <br />