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APPLICATION FOR WELUPUMP PER /,e Lu de t <br /> SAQUIN COUNTY PUBLIC HEALTH S ICES <br /> ENVIRONMENTAL HEALTH DIVISIO �'1 <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 O �Z <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TrlpBfittel <br /> APPLICATION IS NINE BY MADE TO THE SAN JOAQUIN COUNTY FOR-A PERMIT TO CONSTRUCT AND/On INSTALL THE WOW DESCRIBED.TIIIS APPLICATION IS MADE IN COMPLIANCE WTTN SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 8-1/1116.7 AND THE STANDARDS OF BAN JOAQUIN CO(U1N/�TY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADONESS/OR AFH, 3710 1/A1(IO)N I P NLle I^ CITY J]OC/C71ti PARCEL SIZEIAPN/ <br /> S&4'W'5 'Dry Gleectii^ b' tic(wnT� (SD Ds) /900 Powell >I-,ee /a V" <br /> OWNER'SNAMEC/OT)-.., ICI T. Brat T'R _U LD;.�e-F.-le,Eey9PmxLAODNESe ,-I C,4 9,f608 -/8a7 ATONE 951 -(oso7-y.S00 <br /> CONTRACTOR ADDRESS UC/ PHONE/ <br /> ribs w;9 a <br /> BVB CONTRACTOR QO /-1J +- _ _ADORF68 SJ- C�l�++ CA 9jtr 0_' LIcl C57-S/,?d6PPHONE Ie?09-516S-87 <br /> TYPE OF WELL/PUMP: ® NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL! ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSSONNECT/REPAIR [I VAPOR EXTRACTION WELL/ J <br /> 11 New❑Reneh N.P. OEM"PUMP SET ///H FT. FIRST WATER LEVEL 0 <br /> ITYPE OF PUMP( L WELLWELL�� <br /> ❑ OVf-0F6EPVICE WELL ❑ OEOPLIY61CA ! ❑ SOIL BORING R <br /> ❑DESTRUCTION! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 6PECIFICATIONt q r4 <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION p �Y r� DIA.OF CONDUCTOR CASINO /1f/A D <br /> ❑ DOMESTICR'RIVATE ®GRAVEL PACK/SIZE # �61 TYPEOFCASINO/STEEL/ C.1509 //0 Y✓C DIA.OF WELL CASINO D <br /> ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL .3OI SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY :D Ile YI c GROUT BRAND NAME.t/PQD1 Eye)"eAl2�_ E <br /> ® MONITORING GROUT SEAL PIMPED: ®Yr ❑Ne CONCRETE PECESTAL RY DPILLEN:®Y« ❑Ne 5 <br /> n / <br /> APPROX.DEPT"_ y O LOCKING CHESTER BOX/STOVE PPE VP.S 5 <br /> PBOMME,COMSMUCTIONSXtlWNO METHOD: MUD ROTARY AIR ROTARY AUGER X _CABLE OTHER <br /> I HENEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND 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'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR W141CH <br /> THIS PERMIT IS ISSUED,I SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.- CONTRACTO W S HIRING OR SVB.CONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WORKMAM't COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT M'UUIET,�CALL 34 pVRG IN ADVANCE FOR ALL REQUIMID INSPECTIONS AT ISDN(4{t/-8J 22. COMPLETE DRAWING AT LOWER AREA PIIOVID D. <br /> sI'n I%_��' &Z216= - .`i Till. �P �)-(J (� / I(,(MQ q l� Dete <br /> POT MN(privy Ie Ike.(U.l. m �\/T <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PnFIPOSED <br /> Z. OUTLINE OF THE PROPERTY,GIVING DIMENI MINS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> G. 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 SVC"AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING POPERTY. <br /> I " J /i jJ LLQ G�► ecC <br /> DEPARTMENT USE ONLY <br /> 94� <br /> A"k.11en A..,.I l BY D.1. <br /> n'.,e IMPeellen 8, en <br /> D.le __ PP I..n«IIOn BY D.I. <br /> O«IncSen In.n«San By Dae <br /> P.1.' <br /> ACCOUNTING ONLY: AID! FAC! <br /> 9_91"'M <br /> AMOUNT NFMCHECKIMASH RECEIVED BY DATE PERMITISEHNCE REQUEST NUTABEIi INVOICE <br /> 0 <br /> Pub.Health Sew.-Enviro.173(1197) <br />