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call <br /> `' '' APPLICATION FOR INELLIPUMP PERMIT <br /> tw+SAN JOAOUIN COUNTY PUBLIC HEALTH SER4S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 386, 304 EAST WEBER AVENUE, STOCKTONa CA 9520 <br /> (209) 488.3420 �fMENT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RECEIVED <br /> (ComPlaAPPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT IAND/ORI INSTALL THE WOW DESCRIBED.T el U E C r 1�.�ee3 [1.4e.. ,�5,rAv�y�yvv N <br /> JOAQUIN COUNTY DEVELOPM TITLE,CHAPTER P-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE ft�Pr+jStl1RI�EVMPIANCE WITH SAN L l o s� f @igl" N�SBa!NFASERN(DE& <br /> JOB ADDRESS/OP APN* �I V PNM;PHA&HfAj.TH piVIFION <br /> {ry�L1r//�1'� IJ�V/11 I/-�{t/ rl Cm A 81 E/API1 <br /> OWNER'S NAME��11 Y_q,`,0 � �x,_1�f ADDRESS L.J O�^ P' <br /> COMPACTOR T Ch1 U�1V.tN.I �Q`T�'\ S�VL�^-b ^J�D /' 1 ,{�� PHONE/ �J p/ <br /> AOGRESS�G CAMN'KiyL VYI —J, 6s��� R10NE �}'O�SO <br /> BUB CONTRACTOR ly IC� I �IA.) C ADDRESS <br /> YYY UCf RHONE i <br /> TYPE OF WEWPIMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f ❑ OTHER - <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL* <br /> J <br /> ❑Naw❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> RYPE OF PUMP O <br /> 11OVT-0 �.JF-SERVICE WELL ❑ GEOPHYSICAL WELL i 1X SOIL BORING S <br /> ❑DESTRUCTION: I/ \ <br /> INTENDED USE YPE OR WELL CONSTRUCTION SPECIFICATION{ <br /> ❑ INDUSTRIAL ❑OPEN BOTTOMA <br /> DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> ❑ DUBLIC) UNICIP TE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASINO <br /> I O <br /> ❑ P18UCIMVNICIPAL ❑DRIVENOTHER DEPTH OF GROUT BEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING I � GROUT SEAL PIMPED: Ely. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y. ❑N. 5 i <br /> APPROX.DEPTH LOCKING CHESTER SOXNITOVE PPE ^y S <br /> PROPOSED CONSTAMTIONRNOWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER F� ICI'CL <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE W01K WILL BE DONE IN ACCORDANCE WITH SAN JOAMIN COUNTY ORDINANCES,STATELAW.,AND RULE.AND i <br /> REGULATIONS OF THE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLO 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA. TH�APPLI1C^ANT� MUST CALL 24 RROLIHB IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120514YJ422. COMPLETE DRAWING AT LOWER AREA PROVID <br /> SlomdX �Y _,_ TiO. <br /> One <br /> q © ' <br /> PLOT PIAN(m.to 8aYa1 Bwle 'to�'� <br /> 1. NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING 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 /> 0 <br /> ju Sit <br /> R <br /> H _ _ <br /> I �ar_a <br /> t I • I <br /> b <br /> { DEPARTMENT USE ONLY <br /> Application Acnapteci BY Date / Ar. <br /> Gann ImpeoOon 8, Date PvmP Imp..en BY Data <br /> D.trmGen Impaction BY Data <br /> Commenu: <br /> ACCOUNTNG OILY: AIDE FAC* <br /> PE CODES FEE INFO AMOUNT REMITTED C /CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 6 <br />