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LICATION FOR WELL. PUMP PERMIT t:'� i f!
<br /> SAN JOPAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION
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<br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202
<br /> (209) 468-3420
<br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE
<br /> J. (Complltl In Tri llcsll)
<br /> APPtICATION IS HERE SY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED:THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN
<br /> JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICER ENV)F�GNMEP;TAL�1EALTFi DIVI810,N, -.
<br /> Job ADDRESS/OR APN/ rYQ n ,�7 2. Oce CITY 77,L y - .�rl F'PARCEL.8IZElAPNS
<br /> + 'OWNEV'S NAME--�f/I((_Q /Y/�(/�r/�I ADDRESS �PF' /1 T 1'" 4 IQ1m4 ?° PHONE I ..
<br /> C ' CD>� 1y86F�s:�ss'l�4 ?*;�uci�Is ���r . �.1 608'.916
<br /> CONT MCTOR ADORE PHQNE / q Q
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<br /> FLUB CONTRACTOR .t 4 , ADDRE86 -;^2' 1 I^ 'S.�.` Lf�,l� PF{ONF,/��b v'<�.�L'./ S
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<br /> ttt. TYPE OF WELL.(PUMP; NEW WELLS' : ❑•REPLACEMENT WELL ��MONFTOMNO WELL-F' �'• il� {�Y;`�❑ QTf{ER
<br /> 'r° s El INSTALLATION .❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR r} �'1.�'y ❑ VAPOR EX ION
<br /> t % r�•�t -!�A<,t<:JurLT"z 'f+ '14kc ky, T
<br /> r ` ❑New I—Repelr H P. DEPTH PUMP SETZd. t5 Oj, FL rwr;ai R-'"YPE OF PV- ❑.OUT-OF-SERVICE
<br /> - r S»'' 4 ^L�x•`a4t.b�`G f�9 S JJ,°"t�
<br /> OUT OF-SERVICE WELL
<br /> BMP) 4 -
<br />.e i°. :,❑DESTRUCTION:
<br /> INTENDED USE TYPE_ Off: CONSTRUCTION SPECIFICATIONS A ttk t ,ya,X�r4}_ a
<br /> :.❑ INDU8TRIAL ❑OPEN BOTTOM ;` DIA.OF WELL EXCAVATION u »�I C NpUc �81tNO'li,S. "r?tr�4i+�fhl' O -
<br /> ' ❑ [�M ,..r.•;, �:,r - ., ,; dTyZ Y r ',WU .i?
<br /> EBTIC,T'fU VATE GRAVEL PACKISIZE TYPE OF CASINGlSTEELJPVC OIA OF WELLC SING"Y'�''r
<br /> �,❑ PUSUC,'MUNICIPAL DRIVEN kMlbv'r„t, DEPTH OF GROUT SEALSF`ECIFICATI4N�''
<br /> Nbr TM' ),. ::XssftNAtY N.Yi k 14 /❑ IRRIGATION/AG.,: ❑OTHER' M �PYnsl'ii -ORO UT SEAL INSTALLED BY ORO UT.-
<br /> BRAND NAME atL'�IF�Mfn'�"r E
<br /> MONITORINQ ' ' �y-, GROUT SEAL PUMPED: 11 Yee ❑No t CONCRETE PEDESTAL BX DNLLER ❑kd ❑IN
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<br /> APPROX.DEPTH -CC e LOCKING CHESTER BOX/STOVEPIPE '•:- T -\.�?'°'°T.�e+r�t - ti 3
<br /> PROPOSED CONSTRUCTIONrMLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER rv;.
<br /> •. ... _ .- ,yam u: _
<br /> I HEREBY.CERTIFY THAT 1 HAVE PREPARED THIS APPUCATION 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 OFJHE WOF1(FOR WHICH
<br /> -T1418 PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS.OF CALIFORNIA.-CONTRACTOR'S HIRING,OR,BUB-CDf7TMCTINO SIONATUR�,I ERTIFIES
<br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOFYC FOR WHICH THIS PERMIT I8 ISSUED I SHALL EMPLOY PERSONS�BUBJECT TO,;WORIOd AM'1 CQMfETJ..,e�A�TION LAWS OF
<br /> CALIFQRNIA.'.TH�AP CANT.M /CALL 24 F10UM IN ADVANCE FOR ALL REQUIRED INAMT10N4 AT(201)40113421 COMPLETE Dt WINO ATL WE �IDED1.t"7i'rTs�
<br /> SIC"d X.. Tltle
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<br /> i - l,.. ,.;,.PLOT PIAN IDr to"el Boole
<br /> 1;'NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY ' + r 4 LOCATION OF HOUSE 8EW(1GE„QI 8A4,�,Y EM�1R Pg01'O GSD 5}
<br /> '.2,;:OUTLINE OF THE F'RO F'ERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 1 t,y EXPAN 810F(OF.BEWgO Ft OJ8 ,8AL 4'�,Qjk�Q�`' 1 *� S^ 1 K
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<br /> 3. DIMENSIONED,OUTLINES AND LOCATION OF ALL'EXIBTINQ,AND,PROPOSEDs.:' t r/Mt; �� G ir:LOCATION OF,WELLS WITHIN.,MOIV4,OFAN HUND 7 Qy FIFTY,FT
<br /> `STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND—., ':�'ON THE F'ROPEFTTYOR ADJOINING PROPEFTTYs,f-L c, .
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