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+, APPLICATION fOR WELL PUMP PERMIT <br /> 1 SAN JOAOUIN COUNTY PUELID HEALTH SERYIG <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O.BOX 388,304 EAST WEBER AVENUE.STOCKTON.CA 95201388 <br /> 12091 460-3420 <br /> ON-REFUN ABLE PERMIT EXPIRES 1 YEAR FROM D TE ISSUED <br /> ICBmplatl In Trip katrl <br /> APPLICATION 18 HERE BY MADE 70 THE BAN JoAOUIN COUNTY FORA PERMIT TO CONSTRUCT ARVID I INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPUANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHLA{PTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN CODUHIY PU uC FAN USERVICER-EN1410WIN�TpAL HEALTH DIVISION. <br /> JOB ADDRESSMFt APN w, ,4e wnN t C J r�'[QYIi�n-, 1A <br /> yocy�ELCe111�ihPN1�`'J2•�Lt�FO'Q3Q <br /> OWNER'S NAME a J - ` AOOREBS� �� ✓�� .7`�CJ�"}�PFiONE r �F�] 1 YD + <br /> CONTRACTOR �'�W 6V` * ADORES O ��� LICS J[1f.I S9 PHONE f�'1e�I-}Q2.1 <br /> BUB CONTRACTOR�'`t SC P. �1V Y'O�P '_�" { 6� <br /> ADDRESS LICK 1110HE F 67_Y56� <br /> ' n <br /> TYPE or mu/RLMP: 13 NEW WELL ❑MPLACEMENT WELL ❑MONITORING V aLL r ❑OTHER <br /> ❑INSTALLATION ❑WELL sYsTEM REPAIR ❑CROSSCONNE OT REPAIR ❑VAPOR EXTRACTION WELL■ J <br /> ClN..13Rpp.h H.P. DEPTH PUMP SET F7. FIRST WATER LEVEL Tj <br /> RYPE OF PIMP{ �...� <br /> ❑OUT-0F-SERVICE WELL ❑GEOPHYSICAL WELL r 8 <br /> ❑DESTRUCTION: <br /> =K0 D U!l IVPK OF WELL CONS tlC N SPECT CATIO S A <br /> ❑INOU5TRGAL 0OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p <br /> ❑DOMESTICIPRIVATE ❑GRAVEL FACXJSRE TYPE OF CAWNGtOTEEL/PVC DIA.OF WELL CASINO D <br /> ❑PURUCMUNICIPAL ❑OFUVEN DEPTH OF GROUT SEAL SPECIFICATION q <br /> D IIWOATtOWAa 11 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONITORING GROUT SEAL PUMPED:❑Y- [IN. CONCRETE PEDESTAL BY DRILLER:❑Y- [3t" 3 <br /> APPROX,OWTH LOCKING CNEStE BOXISTOVE <br /> PPE---S <br /> PROPOSED CONSTRUCTIONtDRIWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER GC.m p`r� <br /> I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE HONE W JCCOADANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> REOU AYIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGFNT'G SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHR:H <br /> I THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS BU41JICT TO WORYMAN'S COMMEATION LAIAS OF CALIFORNIA.- CONTRACTOR'S HIRING oR W16CONTRACTING SMNATR/RE CERTIFIES <br /> THE FOLLOWING; 'I CERTIFY THAT IN THE PEIIFORMANCE OF THE WOAL Fon WHICH THIS PERMr7 Is BSUEb,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T DAN�TLMUUST CALL 74 HOURS IN RECLAIMED FOR ALL REORED INSPECTIONS OS <br /> # I4SS�47S.COMPETE. NO AT LOWER AREA PROVIDED, <br /> 04.w X �� <br /> PLOT PLAN G)r.p.I.spat.)Sul• 't <br /> 1.NAMES OF STREET �18 <br /> NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF MOUSE 9EWAOE 018P08AL SYSTEM oR PROPOSED <br /> 7. OUTLINE OFT PROIVING DIMENSIONS AND NORrH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTEMa. <br /> 9. DIMENSIONED OUFUNES AND LOCATION OF ALL EXISTING AND PROPOSED E.LOCATION OF WFILS WITHIN RADIUS OF ONE HONORED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> ... ....... <br /> ....... ...... <br /> Y. <br /> DEPARTMENT USE ONLY 11 <br /> Apppp.11m ApeglW sY O.I. Y�- <br /> Arr <br /> Grout InpmIlpt.BY Ota P—P I-P. Itl BY D.t. <br /> I <br /> Ortructl.n Inpwtbn BY D.ta <br /> CemmamR• <br /> ACCOUNTING ONLY: = NDS PAC# <br /> PE CODES FEE INFO AMOUNT RERNlTE. CHECKrg3ASH RECEIVED SY DATE PEF04TIOUMCE REOUEST NUMBER INVOICE <br /> '� 3(05 tll• oto <br />