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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.SOX 988,304 EAST WEBER AVENUE,STOCKTDN,OA 9 of w <br /> Cry 12091481.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> (ComplPb In Tr4RalE) <br /> APPLICAMN 18 HERE BY MADE TO THE IAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR(LIESCRHED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER S.1115.3 AND T�'�_BTAHD BOF IAN IOAWIN COUNTY PUBLIC HEALTH 6E/R�VICEIg <br /> e,ENNHMEMAI HEALTH p(y1IpN, <br /> JOB ADORESBAR APNI�`�,Cb^�" <br /> CITY OC �(J� <br /> �-IT7 <br /> JPARCEL <br /> SIIZEIANI <br /> OWNER'S NAME P.11f <br /> CONTRACTOR � LIC/ KO <br /> (- <br /> NE F -G. LICE PHONEsue coNrRAcran <br /> F <br /> TYPE OF WEU/PUMP ❑NEW WILL ❑REPLACEMENT WELL ❑MONITORING WELL I �OTNEn <br /> ANSTAILATON ❑WELL SYSTEM REPAIR Cl CROSSCONNECT nEPAIR <br /> ❑VAPOR EXTRACTION WELL S` J <br /> i <br /> e 1114—❑Rwk H.P. DEPTH PUMPS" R. � FIRST WATER LEVEL p <br /> (TYPE OF PUMM <br /> ❑OUT-0F-eERVICE WELL ❑GEOPHYSICAL WELL/ ❑ SOIL BORING : S <br /> ❑ <br /> DESTRUCTION: <br /> INTENDED US YPS OF WKUL CONSTRUCTION LPECIRCATIONB !\U A <br /> AINOUSTRAL PEN BOTTOM OLA.OF WELL EXCAVATION V DHA.OF CONDUCTORCANNG 0 <br /> ❑00MESTICMSVATT ❑OMVEL PACIUSQE TYPE OF CASI NO/STEELPVC �74-q DIA.OF WELL C... 0 <br /> ❑PUBLIC WUNICWAL [I DRIVEN DEPTH OF OROUi SEAL SPECIFICATION A <br /> �❑l IRRIGATION/AO ❑OTHER GROUT REAL NHeTALLED BY OROUT SAANO NAME E <br /> Y I L I GROAT REAL PUMPED:11Y- ClM. CONCRETE PEDESTAL RY DRILLER❑Y.P 13N. s <br /> LA�/►Alfl LOCRNO CHESTER SOXMTOVE WE S <br /> PROPOSED CONSTRUCTLOMMOLUNO MST/IDO'. MUD ROTARY AIR RIOTAAY AUOER CABLE OT/lEll <br /> I HE'ERY CERTIFY THAT I HAVE PREPARED THR APPLICATION AND THAT THE WOR(WILL BE DONE M ACCORDANCE WITH BM JOAQUIN COUNTY ORDMANCES.STATE LAWS,AND RITES ANO <br /> REGULATIONS OF THE SAN JOAOUN COUNTY.HOME OWNER OR LICENSED AOENT'8 SIGNATURE CEATWES THE FOLLOWSEO:'I CERTIFY THAT IN THE PEWOAMANCE OF THE WORK FOR WHICH <br /> TWO PERMIT It ISOMD,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOROMAN'S COMPENSATION LAWS OF CAlIFORlBA.'CONITRAITOR'8 HIR/IG OR BIISCONTRACTM SIOHATURE CERrwwg <br /> THE FOLLOW( I RTIFV THAT MTF' 11FOHA ANCE OF E" R WHICH THIS PERMIT IB ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORIUMAN'S COMPENSATION LAWS OF <br /> CAl1FORMA. T PPI-Wy M STC Z NOW IN ANCE FOA REOLMEDJ�LNBP.NB AT 1.1 4011i.LA.COMPLETE L)F.r1Uc AT LOWER AREA R1pyDEp. <br /> 6&.-.d X_ nn. /�t `w'Y YVJ ITS ���-��1VGGl•'� 0.1. <br /> PLOT PLAN(Drew Iv Se l sl 'ro <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNONO THE PROPERTY. B. LOCATION OF HOUSE SEWAGE dePoOAL SYSTEM On PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,Or~DIMENSION#AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> ].DIMENSIONED OUTUNFQ AND LOCATION OF ALL EXISTNIG AND PROPOSED f.LOCATION OF WELLS WITmN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES, COVERED AREAS CTURES,INSUCH A8 PATIOS,DRIVEWAYS,AND WALKS, ON THE PRLOfEITTY OR ADJONNO PROPERTY. <br /> 4VE <br /> Q� <br /> ;C1 <br /> 1 N5'(avv°_pl�ly <br /> Agcor-I <br /> ... .... .... <br /> are.A Irwpectivn "I OI,BDE,PARTMIEINT"U/SE ONLY <br /> APPllebn A—lW By. to/VI <br /> A,. <br /> Br <br /> P—P k.P.auoo Br oa. <br /> Oslrtrvtbn Irvpevtim Br Oele <br /> C vmmenrP <br /> ACCOUHn..ONLY: ATOP FACP <br /> FE CODES FEE INFO AMOUNT REMITTED CHECKOICASH RECEIVED SY DATE P TISERWE RECUEAT NUAYEA INVOICE <br /> i <br />