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APPLICATION FOR WELLIPUMP PERMIT <br /> SAII&AQUIN COUNTY PUBLIC HEALTH SEerES <br /> ENVIRONMENTAL HEALTH DIVISION""'ll"' <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Trlplk{te) <br /> APPLICATION IS HEM BY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.T PPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TILE;CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY�DU/TY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR AEN/ rb -/; O AI CITY PARCEL <br /> �Q .^^'Dr �n+nce�a� •�L T+,..e�. Sb�yDi l4eo F P <br /> OWNER'S NAME O/e 'D SIOLyT. 'R m�A,sr• .•IlwC��n'C!A eM A,.Mae v%/gyp} CI1 9Yir60 __ PHONE/�5'io)(o-S7-S'oao <br /> CONTRACTOR ADDRESS LJL/ PHONE/ <br /> y� ( e St <br /> SUBCONTRACTOR `PrCC/'s'-c-, S (vri ADOMSS s• "' a 1 Cog 9Y 9a! uc/csJ-6363Y7%ZONE/�Yndv/s6-987 <br /> TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPI-ACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR099CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑Nmv❑R«.Ir H 0. DEPTH PUMP SET_---FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OUT-OFSERVICE WEII ❑ GEOPHYSICAL WELL/ 601E BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS {} A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION -*4A p3 I NL 1k DIA,OF CONDUCTOR CASING pN'f O <br /> ❑ DOME9TIC/%BVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELI'VC NA VIA.OF WELL CASINO vI'JI1p ♦ �r O <br /> ❑ PIHBLICIAUNICIPAL <br /> 11 DRIVEN DEPTH OF GROW SEAL T'ZI - p- SPECIFICATION CPVaE V'1 IpJ,f WlONlI'Q B <br /> A❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY Q R1I_It OROLR BRAND NAME <br /> �( Nr) <br /> ITL MONITORING GROUT SEAL PLUMPED: ay. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yw I�,JJJvff�� E <br /> S <br /> APPRO X.DEPTH <50' LOCKING CHESTER BOX/STOVE%PE S <br /> PROPOSED CONSTRUCTIONIDRJLUNO METHOD: MUD IKITARY AIR ROTARY AUGE0. CABLE OTHER 1 r i YR•„FI� 1"0511 <br /> I HEnEBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AVIV THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'SSIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUR-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMR IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF <br /> CALIFORNIA: THE APPLICANT MUST CALL 24 HOURS IN <br /> ADVANCE FOR ALL REQUIRED IINSP/ECTION{AT(t )/4BB1J 23. COMPLETE DRAWING AT LOWER AREA%WNOEO. <br /> eIP� \L 1--7-�J nu. rJ 72- �rO�P -1` /"12rlaa 2� O.t. <br /> PLOT PLAN R),.I.6c.l.1 Sole 1. <br /> I. NAMES of STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DIBPOBAL SYSTEM On PMI`06ED <br /> MS <br /> 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION SEWAGE DISPOSAL SOF ONE HUNDRED FIFTY <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OFF WELLS WITHIN RADIUS OF ONf1. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING{`IIDPEIiTY. <br /> I " JHf� �f�•4. c.� ecC. <br /> I' <br /> i <br /> DEPARTMENT USE ONLY <br /> APRllc.11an AmnplM BY V.I. <br /> G'w IrrcP«Son BY D.P. P ;P Irmo«9an BY D.P. <br /> D <br /> De.4meen tmn««jII.Rev <br /> T <br /> ACCOUNTING ONLY: MD/ FAC/ <br /> PE CODES FEE INTO AMOUNT REMITTED CHECKI/CASH RECEIVED BY DATE PENMITISEAVICE REQUEST NUMBER INVOICE <br /> Pub.Health Sew.-Enviro.173(1197) <br />