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* APPLICATION PAR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201386 <br /> (209) 488.3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TIT UE,CHAPTER <br /> .A9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSMR APN# dD'? Wye�s? A7 ell"/( �Ve CHITv Jr 70C/TZ✓) / SO <br /> SIZE/APIJI �1`n�(I QC lP_S <br /> m / Y)Id - 6Q l fAm1Ly IQ, 1ADORESSLOI C� CGFAN �L��TTt SIJ I�nQ�PHONE# KJ • -1-0 12 <br /> OWNER'S NAME X- <br /> /6 9ao- <br /> CONTRACTOR LL ADDRESS SOt�o rnPirlFO UC# PHONE0 0300 <br /> SUBCONTRACTOR S�cie m, / ADDRESS Z�Y'n A" UC;F <br /> 1� <br /> � L Y <br /> TYPE OF WELUPUMP: O NEW WELL ❑ REPLACEMENT WELL MONRORING WELL/��rt P y ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> ❑New❑Repel, H.P. DEPTH PUMP SET-ff. FIRST WATER LEVEL O <br /> (TYPE OF PUMP( <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ 801E BORING R <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPEOF WELL CONSTRUCTION SPECIFICATIONS ,/ A <br /> ❑ INDUSTRIAL r❑O NBOTTOM ,J� DIA.OF WELL EXCAVATION p� /I'!C� DIA.OF CONDUCTOR CASING N�O D <br /> ❑ DOMESTIC/PRIVATE ICI GRAVEL PACK/SIZE ZOi1r5*r03 TYPE OFCASING/STEELR'VC / I/C- t DIA.OF WELL CASING D <br /> ❑ PUBLICRdUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL S'//7 iC2P / SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY r1� GROUT BRAND NAME r-�/ E <br /> I{7 MONITORING GROUT SEAL PUMPED: [I Y. GYN. CONCRETE PEDESTAL BY DRILLER:LTJ Yr [IN. S <br /> APPROX.DEPTH 0.5- Ye C. LOCKING CHESTER BOX/STOVE RPE StdVle i P S <br /> PROPOSED CONSTRI/CTIONAIR LUNG METHOD: MUD ROTARY AIR ROTARY AUGER 6"' CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES ANC <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 WHICF <br /> THISMUO <br /> 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-0 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> T JG: I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FORWHICH THIS PERMIT IB IS6VED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFNBATION UWB OI <br /> C ITHE APPUCA T M T CAL, 41 URS IN ADVANCE FOR ALL REQUIRED IN•/SP/�y�T//IONN�S AT 1208148aJ42e. COMPLETE DRAWINGAT LOWER AREA PROVIDED.81SrwTBI. /' /�; 1.- <br /> PLOT PUN(Drew to 6eeb)6g1. 'to <br /> 1. NAMES OF STREETS OR ROADS ST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMSED <br /> 2. OUTLINE OF THE PROPERTY,GIVI 0 DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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 /> l <br /> DEPARTMENT USE ONLY <br /> Appllmtlon Accepted By Dtle /y Area T <br /> Grout IMI,Wlon 8Y Dete Pump In.,.tlon By Deta <br /> DsvmUon I pectlon BY Dne <br /> Comment.: 3 5/ mss, ray !—s3 a Y ce-�-<<-c C't/12uJ4c8 Ir 4�,1csytC <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE COD" FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> Ro 1 foo 47� 14 -20-76 0L/9(0 6 <br />