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PPLICATION FOR WELL/PUMP PER <br /> SA AOUIN COUNTY PUBLIC HEALTH SCES / �,f} <br /> ENVIRONMENTAL HEALTH DIVISION zl <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 24 <br /> MOM-REFUNDABLE PERMIT EXPIRES 1 YEAH FROM DATE ISSUED <br /> maDlplela In TrlpRaatal <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH BAN <br /> £--- JOAQUIN COUNTY DEVELO�PIMENT TITLE,CHAPTER 9-11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OMSION, <br /> JOB AODREBRJOR A�PN�feS �ai �G�c�� Gi�,/�� CITY —PARCEL SIZEIAPNI_Z2U —6t4Z!/ <br /> OWNER'S NAME I TJ{JJ ADDRESS /C/ PHONE IF f f J <br /> CONTRACTOR��.1/+91Cng? 1 /LJIIL X} AOORESI�r�p,� /1/,r/UU,S�LJCI �r}TONE I ! <br /> RUB CONTRACTOR` ,--,/ ADDRESS Loco PHONE P <br /> TYPE OF WELLIPUMP: ❑y `MEW WELL ElREPLACEMENT WM LSI MONITORING WELL 9 &l ❑ OTHER <br /> Lyr6CiALLATNIH ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTFJN WELL I <br /> ❑New LJ Repair M.P. DEPTH PUMP SET FT, FIRST WATER LEVEL 0 flly\ <br /> (TYPE OF PUMPI <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL P ❑ SOn.BORINJ B f A <br /> ❑Df6TRUCTION• V Ilr <br /> INTENDED USE TYPE O WEIZ CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO O <br /> ❑ ooMESTICIPRIVATE ❑GRAVEL PACKISIIE TYPE OF CASN0/87 EEL1� DIA.OF WELL CASINO <br /> D PUIBUCIMUMCIPAL ❑DRIVEN DEPTH Of GROUT BEAL SPECIFICATION n <br /> ❑ m GATIONlAG ❑OTHER GROUT BEAL INSTALLED BY s>n GROUT BRAND NAME E <br /> MTORINO !11 GROUT SEAL PUMPED; ❑Yr ❑No CONCRETE PEDESTAL BY DRILLER:❑Yam ❑Ne S <br /> APPtOX_DFPT" { LOMPM CHESTER BOXIBTOVE PPE S <br /> PROPOSED CONBTRUCTIONIONLUNO METHOD: MUD ROTAITY AIR ROTARY AUGER 1.` ,CABLE OTHER 1 „ <br /> 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIN APPLICATION Aldo THAT THE WORK WILL BE DONE IN ACCORDANCE WITF4 BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND V <br /> 11EQUTATION6 OF THE RAN JOAQUIN COUNTY, HOME OWNER OR UCENMO AGENT'S 01ONATUAE CERTIFIES THE FOLLOWINO.-•I CERTIFY THAT IN THE PERFORMANCE OF THE VMPIK FOR WHK:H <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORIMAN'4 COMPENSATION LAWS OF CALIFORNiA.• CONTRACTOR'S HIRING OR SUB-CONTRACT1Ne SIGNATURE CERTIFIES <br /> THE FOLLOWING; 'I CERTIFY THAT RJ THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPUCA MUNI CALL 21.H0 IN ADVAMCE FOR ALL IIEGUXRM INSPECTNINll AT 120111440-3422. COMPLETE DRAWING AT LOWER AREA F140OVIOED. Q� <br /> Slpned X-- -- This L / bate <br /> PLOT PLAN mew w Sa lel Seale to <br /> I- NAMER OF STREETS OR ROADS NEAREST TO OA BOUNDING THE PROPERTY, 4_ LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF TILE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS_ <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT_ <br /> STRUCTURES,INCLUDING COVEMb AREAS SUCH All PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> � OEPl4HTMENT USE ONLY <br /> APplleatlen Aaeeple,l By l <br /> Gaul I—P-11"By sl IR,�yq(7 L, ,T Owe Py p Iropeetlan BY Dote <br /> D"lomllen hNpeellen By_ Date <br /> Cemmenl.� <br /> ACCOUNTING ONLY; AID# FACA <br /> PE CODVIA FEE INFO AMOUNT RETMTTED CHECKFICANH RECEIVED BY DATE PERNITISERVICE PEOLIEaT NUMBER INVOICE <br /> 5c>l A 941 now <br /> oars 7D <br /> Pub,Heakh Serv,-Enviro.173(1/97) <br /> .r <br />