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APPLICATION FOR WELIIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN JOAQUIN ST,STOCKTON,CA 95201.388 <br /> (2091 468420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICBmpYtu in Tripl abl <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CON67FRULY ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY P1161JC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. <br /> JOB ADDREBS/oRAM# 7735 S. RT 99 WEST FRONTAGE RD' ST0CKT0N PARCEL SIZEJAPW <br /> OWNER'S NAME DAVID RAKOVICH ADDRESS 5220 N. ASHLEY.STOCKUA4ONES 952-3129 <br /> CONTRACTOR)EMMINGS BROS DRILLING Co -_ ADDIcSS 3525 PELANDALEuucc:U"219081 IHONEF 545-1185 <br /> I <br /> SUBCONTRACTOR ,,qq ADDRESS UCP PHONED <br /> TYPE OF WELLMUMP: IM NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL S ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELLS ✓ <br /> 13 m—OA-siv H.P. DEPTH PUMP SET_Fr. RAST WATER LEVEL 0 <br /> ITYPE OF PUM% <br /> ❑OUTVF-SERVICE WELL ❑GEOPHYSICAL WELL F ❑ SOIL BORING a ._.1 <br /> ❑DESTRUCTION: J <br /> INTFNP D USE TYPE OP Wi1L CONSTRLOCTION SPECIFICA NS <br /> ❑INDUSTRIAL p❑p1I OPEN BOTTOM DIA.OF WELL EXCAVATION 20" DIA.OF CONDUCTOR CASING O <br /> ❑ <br /> DOMESTIC/PRIVATE yy GMVEL PACK/SIZE TYPE OF CASING/Sr JPVC PVC DIA.OF WELL CASINO 1 D II _ D <br /> �A <br /> ❑puuJC/MUNICIPAL ❑DWVEN DEPTH OF GROUT SEAL 1 D 1• SPECIFICATION R FNTDNT TF A <br /> Q IRmATIOWAG ❑OTHER GROUT SEAL INSTALLED BY H E N N I N G S GROUT BRAND NAMEIOP-LI E <br /> ❑MONITOPTNG GROUT SEAL PUMPED:QYr 3 Ne CONCRETE PEDESTAL BY DRLLFR:❑ KIN.N. S <br /> APF IOX.OETTH '�V''3O/ LOCKING CHESTER BOXJSTOVE PIPE <br /> RIOPOSED CONSTRUCTIONJDNLLMO M[THOD:MUD ROTARY X AIN ROTARY AUGER CABLE OTHER <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOLE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGUUTIONS OF THE BAN JOAQUIN COUNTY.HOME OWNER DR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> TMIS HERMR a1 <br /> IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR BUSCONTNACTINO SIGNATURE CERTIFIES <br /> ECT TO <br /> CAUFDRNN THE APRICANT.MUS CALL 24 HOW INTHE FOLLOWING; 'I CERTIFY THAT IN THE CADVANCE FOR ALL AVOWED E OF THE WORK MR WHICH INNSSPECPERMIT <br /> ON$AT 1=01 .IS ISSUED,I SHALL EMPLOY <br /> MP ETES DMIMNG AT LOWER AREA PRO10DEpPE11SATON LAWS OF <br /> sP..a xYZflll,bL+ <br /> De. MAY 11 , 1995 <br /> R <br /> . AT PLAN Ilk—m S-NI <br /> 1.NAMES OF STREETS OR ROADS NEAPEST TO OR BOU..NG 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 OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Ff, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> I " Ilftl I I �. <br /> r ` <br /> I <br /> 1 I <br /> J4r I <br /> f I L <br /> �z _... <br /> � rn> <br /> m <br /> 7 1 I vh inr Wim . <br /> °D�.0 w m Z <br /> va <br /> _ IDEPAINMENT USE ONLY <br /> • i <br /> LCroul 61FPeetl-By Dm.'5'�P Irvp.—BY DRe <br /> � <br /> ACCOUNTING ONLY: NDI FAC/ <br /> PE,-- Fa INFO AMOUNT REMITTED CKCK4r/CAW RECSIM BY DATE Pa"T1 MA UFST UMBHI INVOICE <br /> pp 0i <br />