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* APPLICATION FOR WELLIPUMP PERMIT * <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> I2091468-3420 FELE COPY <br /> MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED I <br /> ICamplatt in TripFt6BtBl <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPWNT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH OMMON. <br /> f .L� � i hacr65 <br /> JOB AOORESSNR APNI+ C.O/CT z� SE^_(�_ZOC-} crry s'�"Cy/cK IVvI PARCEL 61=E//�{A/pPNf_ � 163-7i]2`C1t-Ob <br /> OWNER'S NAM /E� /In 1 ,C�f�t _X`i/ .. /�iDORE.- _ {� -YJ /V DL-7(J f✓N Rp/E , ! J.�• �. <br /> CONTRACTOfl_ C NuU I L L ADDRESS `�`d%VL 1 �.0. UCl <br /> L ! 2 I <br /> GLIB CONTRACTOR IY U v-vi (,.711.1�YG( L.,�- ` I 4yZ � y 1�L-� pp PHONE E l ��GG�-/1 <br /> ADDRESS `�\W N"TT�"VL � CGL LIOf ZZ�O PHONE I l-U I <br /> 'TYPE OF WELLPUMP, ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WEL 0 s ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPNR ❑ CROSSLONWE REPAIR ❑ VAPoR EXTRACTION WELL f <br /> 13NAV❑Ra.A, H.P. DEPTH PUMP SIET_FT. FIRST WATER LEVEL 0 <br /> RYM_OF PVMP <br /> ❑ OUTGF6ERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ BOR BORING g <br /> �I DESTRUCTION: <br /> _HTENDM TIDE TYPE OF WELL Nc1 CONSTRUCTION SPECIFICATIONS A <br /> U INDUSTRIAL El OPEN BO OM IVIpA R'YQy DIA.OF WELL EXCAVATION II II DIA.OF CONDUCTOR CASINO D <br /> ft1 % PA [� <br /> ��i1 DOMESPC/RVVATE BRAA4L PApVeRE .�LI.NNL TYPE OF CASINO/STEFI�Vy9yx',7I �V•CG{LIIQ 4V DIA.OF WELL CASINO D <br /> lJ PJBUGMUNICIPAL ❑DRIVEN DEPTH OF GROAT SEAL �rZ tIo n~ L.-,6 7 SPECIFICATION L R <br /> 'J 'RRIGATIUNRAO ❑OTHER GROUT SEAL INSTALLED BY C ORGLR RRAND NAME r C CI"L'VL T F <br /> J MONITORING C`- GROUT SEAL PUMPED: Ys Na CONCRETE PEDESTAL BY OMLER: V. ❑Ne S <br /> "PRO X.DEPTH Sha 11VIA1 12,/ / beep ; S7 ' <br /> LOCKING CHESTER SOXROGVE P I ✓Ct c- 1Z4'SC.d V7(uc,"Mcoo }' s <br /> '^RPOSED CONSTRVCTIONIDIBWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> Tom' <br /> FR£3Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OROINAHC j'S ATE LAWS.AND RULES AND <br /> GULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLG%1M: '1 CERTIFY THAT IN THE PEPPOAI&ANCE OF THE WORK FOR WHICH <br /> ;1118 PERMIT IS ISSUED.I SHALL NOT EMKOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOMB HIRING OR SUBLONTRAQTING SGNATURE CERTIFIES <br /> "HE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> 'AUFORNIA.- TrHE APPLICANT MUST CALL M IGUIAI IN ADVANCE FOR ALL REGLARED INSPECTIONS AT 12041 Ab3A23. COMPLETE ORAVGNG AT LOWER ANEAIPROVIDED. <br /> vlatw X <br /> ROT RAN (01.m MWO 6W. '1. <br /> 1. NAMES OF STREET'S OR POADS NEAREST TO OR BOUNCING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTJ:MB. <br /> .i. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RAD USAOF ONE MJNORED PFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING <br /> 1 <br /> - _ OEPAgTMKNr USE ONLY <br /> PPllenlen Ac..PtM BY - - _._ <br /> ;..v1 Impcl BY 0.1. _ _rbrnP INPeenen BY '• Ow. <br /> OrVwtbn Imq�aGon BY - ,._ 0m. <br /> G.mm.�t.: 1I.�P� D. KP• 5 <br /> ACCOUNTING ONLY: AOT' FACE <br /> PE COOED FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE PEEMITISERVICE REOUEAT NV 9113% INVOICE <br /> 90 "7btul � 2 . 3• <br />