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�rf:,en'r� tl /oI, t. .Ic► - t,. ,.,,r Fa .app-'� r' s T1,'!>< x e J�{" l <br /> APPLICATION FOR WELL1PUMP PERMIT <br /> -SAN`�OAQUIN COUNTY'PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.01%BOX SW 304 EAST WESER AVENUE, STOCKTON. CA SMI-SW <br /> .� ,1 1209) 489.3420 <br /> I <br /> NON RE.FUNDARC PRMITEXPIRES I YEAR FROM DATJ ISSUER <br /> (Complete la MpHuti) <br /> APPLICATION 18 r4FRE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE W COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8 1115 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBIJ N SERVICES,ENVIRONMENTAL jNMTH DIVISION <br /> JOB ADORE88IOR APN/ CJ / / C r . CITY C F/+/[tel C "1 PARCEL 8IMAPN/ t <br /> OWNER S NAME re <br /> / ADDRESS f - PHONE/ <br /> CONTRACTORI ✓O r 1 /1DDiIEBa <br /> au$CONTRACTOR s N r Y fvf ` y , �I � ' IICI <br /> L LIC9 9 ���� E <br /> '«..r �, {,tea r _ <br /> TYPE OF WELMMj ❑ NEW WELL ❑ REPLACEMENT WELLNITORINO WELL PrNO ��,y 13OT"" <br /> 13LNSTAILATION ❑ WELL SYSTEM REPAIR ❑ CROSO4ONNECT REPAIR ❑ VAPOR EXTRACTION WELL B J <br />{TYPEOF Pumm <br /> 13Naw Cl Rap* H P DEPTH PUMP SET PT FIRST WATER d <br /> } ' 13OUT-0FSERVICE WELL © GEOPHYSICAL WELL O 13SOIL BOUND , O <br />❑DESTRUCTIDN ' ~ - <br /> INTENDED i TYPE OF , CONSTRUCTION fEECIFICATIONS A <br />❑ INDUSTRIAL ❑OPEN BOTTOM , DIA OF WELL EXCAVATION DIA OF CONDUCTOR CASINO Q <br />❑ DOMESTIC/PRIVATE RAVEL PACKI8IU TYPE OF CASBIOISTEEL/PVC2 ✓6 DIA.OF WELL CASINO Pt <br />❑ PUBLICIMUNICLPAL ❑DRIVEN DEPTH OF GROUT SEAL 0, SPECIFICATION I R <br /> 11 IRLUGATIONIJW OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F <br /> 0'MONITORING h OROS/T aEAL PUMPED ❑Yw [IN. CONCRETE PEDESTAL$Y DRILLER.(3YM ❑No S <br /> APPROX DIIPTH__ y LOCKING CHESTER BOXISTOVE PIPE <br /> 8 <br /> PROPOSED CONSITMCTION/DIILLING METHOD MUD ROTARY AIR RDTARY AUGER CABLE OTHLj_ <br /> I <br /> Ask <br /> H <br /> CERTIFY I AT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN.)OAOUIN COUNTY OFMKANCES,STATE LAWS,AND JWLES AND <br /> RE TIONS OF IHE SAIL VAOUIN COUNTY HOME OWNER OR LICENSED AGENT'S"NATURE CERTIFIES THE FOLLOWING 'I CERTIFY THAT IN THE PEFMPJAANCE OF THE WOK"R WHICH <br /> THIS PERMIT 19 IS%UEO,I tWLL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'i CO SATION LAWS OF CAUFORNUI• CONTRACTOR S HHUNG OR SU$CONTRACTING SIGNATURE CERruqu <br /> THE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'*COMPENSATION LAWS OP <br /> CALIFO THIl �/NT MUST CULL 24 HOURS IN ADVANCI FOR ALL REOLJIRf�7 INSPiR/TrWNS AT 120S14SS Silt C MAETE pMVVIPW AT WVVEA AREA PNrDVIDED ry <br /> Dot !i 1 / / <br /> PLOT PLAN(Maw to lk."lkv" ^'to <br /> 1 NAMES OF STREETS OP ROADS:NEAREST TO OR BOUNDING THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYErEM OR PROPOSED <br /> 2 OUTLINE OF YHF PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYtrEMs, ' " +- <br /> 3 DIMENSIONED OUTLINES AND LOCATIORLOF ALL EXISTING AND FROPOSEO i LOCATION OF WELL8 VV"WW RADIUS OF ONE HUNDRED FIFTY Pr <br /> STRUCTURES,INCLUDING COVERED AREAb SUCH AS PATIOS,DRIVEWAYS,AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY <br /> ,"r �i.� ++'�'-�^ Y�in67r- ,... 4 � *�_ Y n = + .;cam; „I>�'+ d r � ,� �� s '• � .."4 ,e . i"� I �+�N <br /> s <br /> a <br /> I <br />