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APPLICATION FOIFIRELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 904 FAST WEBER AVENUE, STOCKTON. CA V <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 TARP FROM DATE ISSUED <br /> K4m*10h In Tr4Rratal <br /> APPLICATION Ia HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION Ig MADE IN CriM LIANCE WITH SAN <br /> JOAOUIN COUW Y DEVELOPMENT TITLE.CHAPTER 5-1116.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DRAMON. <br /> ionAmmag/ORAPN, 28U7' 2829 S. HMI 99 cr,Y Stockton* CA PARCELMZEUPN! <br /> OWNER'S NAME ADDRESS Philadelphia, PA WONEI�}. '�'=►`� <br /> cOFITRACTOR Hydro—Search, Inc. ADDRESS Sacramento* CA uC, 6551.53pwm, q7 <br /> SUBCONTRACTOR GreggDrillingADDRESS Martinez* CA �, 4$5165 ,,140,IE,� <br /> TYPE OF WEUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL f 1-3 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBg-CONNECT REPAIR ❑ VAPOR EXTMCTION WELL f J <br /> 11N.❑a%,* H.P. DEPTH PUMP SET FT. FIRST WATTR LEVEL O <br /> RYPE OF PUMP) I� <br /> IO OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL f ❑ @OIL'EORING <br /> CRDESTRUCTION;_ -1 MOnitOr jealls and I out- f-service well b reSack At-f-av of ] In A �•sure routing <br /> IMT D E 1' OFW CONS TIONSPECIFICA NS PP `��Q In _Q1a_ <br /> �y — A <br /> LJ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION TiIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIMPRIVATE ❑GRAVEL PACKMZE_ TYPE OF CASING/STEELIPVC DIA.OF WELL CASING D <br /> ❑ PUSLICIMUNICIPAL ❑DRIVEN DEATH OF GROUT SEAL_ _ SPECIFICATION <br /> ❑ meAnomma ❑OTHER GROUT SEAL IMALLED BY „,- _ GROUT BRAND NAME <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑YM ❑No CONCRETE PEDESTAL BY DRILLER:❑YM ❑Ne <br /> ARPFROX.O@TN LOCKING CHESTER BOXIBTOVE PIPE <br /> PROPOSED CONSTRUCTIONMMLUNO METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER 4- <br /> I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE V1lITH SAN JOAOUMI COUNTY ORDINANCES,STATE LAWS,AND RULES <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WMIKMALN'S COMPENSATION LAWS OF CAIJFORNIA.' CONTRACTOR'S HIRING OR SU"ONTAAGTINO SIGNATURE CE <br /> THE FOLLOWING: '1 CERTIFY THAI M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEIISATION LAWSIZ <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR Ali.REOUR®INSFSCTIONS AT f2d1}4Ma422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> wed O <br /> X �i-/J-- Till.=�r_O.y 1 Date }%T I <br /> PLOT FLAN IOrw to Bawki agate •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDMM3 THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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 /> See: attachedsite. map <br /> F <br /> d O111PARTMEHT USE ONLY <br /> APPtbatlen Aoeepted By / G <br /> Hate � L !f", _M.o +' <br /> If <br /> Grout Irrpeotlon By_ Dote Pump Iropenthm By Dole <br /> 1 <br /> Dellruollan In.peellun By <br /> Dase <br /> 1 <br /> Cemmarrt+: � <br /> ACCOLWTINO ONLY: AID, FAC* r �0`] <br /> J <br /> M CODES FEE INFO AMOUNT RGNITTEb C ASH RB ovn aY DATa Fw"tlS6NIC!IIEGIlEST NIaMS6t INVOICE <br /> 061 r UQ <br />