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APPLICATION FOR WELUPUMP PERMIT _ -- <br /> ��- JOAQUIN COUNTY PUBLIC HEALTH SERVIC <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br /> (209) 408.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR fROM DATE ISSUER <br /> ICGmrlsb In TrylGutol <br /> APPUCATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITTI FM <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER8.11115.3 ANDTHESTANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APN/ M\`TNP'� dl'� <br /> . 1 Q-�Ke (`,t';•'� i�� CY KV 1 _ PAItCEI61ZElAPN1Js! <br /> ��77 (( (``� lxl C` Nay •el- >\� f4 y� -�G � <br /> OWNER'S NAME .Rr <br /> J� % lLc� �S�i�l- LC/ <br /> CONTRACTORAr`e �f IPHONEI '63- '-07�.� <br /> cam,�eS <br /> PHONE• -= <br /> BUB CONTRACTOR �v` I _ADDRESS G <br /> Il <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ mptACEMENT WELL ❑ MOWTORING WELL S ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR Cl CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WEI-S J <br /> ❑N. Rapalr M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL E <br /> (TYPE OF PVMPIS <br /> ❑ OUTOFSEFIVICE WELL ❑ OEOPFTYSICAL WELL I SOIL SORINO <br /> ❑DESTRUCTION: <br /> INTENDED US( W CONiTRUCTION SFECIFiCAT10NE /� A <br /> ❑ INDUSTRIAL Cl OPEN OPEN BOTTOM DIA.OF WELL EXCAVATION ,I DIA.OF CONDUCTOR CASINO hq- O <br /> Cl DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOISTEELIPVC GIA.OF WELL CASING_ /i/Y- 0 <br /> ❑ PUSUCIMUNICIPAL ❑DRIVEN ( DEPTH OF GROUT SEAL �.f`�V��t'\LL�';laG SPECIFICATION <br /> ❑ IRRIOATIONIAG OTHER SCi����\I� GROUT SEAL INSTALLED BY � `1�� OR OUT BRAVO NAME <br /> MONITORING d GROUT SEAL PUMPED:�g Yee ❑No CONCRETE PEDESTAL SY DPoLLER:❑YM []No 5 <br /> APPROX.DEPTH �-U I LOCKING CHESTER BOXJSTOVE PIPE 5 <br /> PROPOSID CONSTRUCTION/DWLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOPK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AM <br /> MOULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUSCONTRACTIHO RIONATURE CER TIFIE <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOnK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPWSATTON LAWS 0 <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN 4VANCE f0 ALL REGWIED INim7IoNS RT 1205)40*4422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slprwd X � ��� Tltl• Y��-.'Z.� ,� ,•t w Dots I <br /> I l <br /> PLAT PLAN IDle to 60e1e1 Booty 'to <br /> 1. NAMES OF STREETS OR ROAD$NEAREST TO OR BOUN04NO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On F'MPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> ]. 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,DAIVEWAYB,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY L <br /> Appllwtbn Aooepted BY D.I. <br /> GIOVL Iropeotlon By Date/d "1 / Pump Inopaatlon By Dote <br /> Drtrwllon I=poction ?/ /,� l n ,✓ D.Comments' - ✓ 4 F l '�" `� <br /> ACCOUNTING ONLY: AIDS FACT <br /> PE CODES PEI INFO AMOUNT ROMITTED CHEC /CATH RECEIVED SY DATE PlII7MMTISSINIQ(REQUEST NUMSSR INVOIC( <br /> N D <br />