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APPLICATION FOR INELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCXTON, CA 96201.388 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ICO -plots M TyipkatD) <br />APPLICATION It HERE By MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR( DESCRIBED. THIS APPLICATION IR MADE IN COMPLIANCE WITH SAN <br />JOAOUBR COUNTY DEVELOPMENTrTTITLE, CHAPTER 9-111 5.3/ AND THE STANDARDS OF SAN JOAQUIN COUNTY/ PUBLIC/HEALTH SERVICES. ENVIFIONMENTAL HEALTH OMSEON, <br />JOB ADORESS,OR APPjNI 6-I / CfTY �/'OG /G 2M /J PARCEL SRFJAPNI <br />ONTlER't NAME <br />/j /A`/`i/ZA//ilJ d Ll/YJ al�o��./ Aool�ea 5///7/JN• 1 reo E/h�x Sfk n (44 RgNEI <br />CONTRACTOR I C'�[/�� — IV ADDRESS Zy-a'} .I/t/- ///4//'C// IGV LIC! RgHE <br />SUS CONTRACTOR 4,0 I / / / n� AODIESE / /(/T�� �• "fes/ �j 7 9 I R10NE I I d' Z <br />TYPE OF WELLIpump.. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING, WELL $ ❑ OTHER <br />❑ INDTALLATION ❑ WELL SYSTEM REPAIR Cl CRO8S-CONNECT REPAIR ❑ VAPOq EMRACTION WELL / J <br />❑ New ❑ R -w, N.P. DEPTH PUMP SET FT. im WATER LEVEL p <br />RY'1`f OF fUMK <br />❑ OUT-OF-RERVOE WELL Cl OEOR/YSgAL WELL I �YJ 8011 BORING 1�i ��� S <br />❑ DEBTRI/CTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIRCATIONE A <br />❑ INDUSTRIAL 11OPEN BOTTOM DIA. OF WELL EXCAVATION A//d DIA, OF CONDUCTOR CASINO 1-114 p <br />❑ DOMEWMIPWVATE ❑GRAVEL PACKWU TYPE OF CASINaMTEEL/PVC /tI4 DA. OF WELL CASINO D <br />❑ RUBLICANR/ICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIRCATION A <br />❑ IiyW ATgM/AO ❑OTHER GROUT SEAL INSTALLED BY OROVi BRAND NAME/,'l E <br />!1`i--'1/MONFTORNO GROUT SEAL PUMPED: ❑ Y� N. CONCRETE PEDESTAL BY DRLLFR: ❑ Yr_2< S <br />APMOX. DEPTH LOCKING CHESTER BOXOROVE NPE16112f� S <br />PROPOSED CONSTRUCTIONRRSWNO METHOD: MUD ROTARY AR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT 1 HAVE PMPARFD TMS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDNANCE$, STATE LAWS. ANO RULES ANO <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CEgTIFR$ THE FOLLOWING: '1 CERTIFY THAT IN THE PEIEORLALANCE OF THE WVOIK FOR WHICN <br />THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY PERSONS SUBJECT TO WORWAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORS HIKNO OR BUB{ONTRA <br />CTWq SIGNATURE CERTIFIED <br />THE FOLLOWING: - I CERTIFY THAT IN THE PERKOAMANCF OF THE WI3 K FOR WHICH THIS PERaMT 18 ISSUED. I MALL EMPLOY PERSONS SUBJECT TO WORgMAN'D COIIFPOI.AT/ON LAWS OF <br />CAUFORMA.' j1 UC M ALL 24 HO ADVANCE FOR ALL RECURRED INSPECTIONS/A TT�+1p2�WE 1NSD•- n. COMPLETE DMW1Fq AT LOWER AREA PROVIDED <br />/./�J <br />Slpr! X <br />PLOT PLAN CO— le Se.Ial Sle le <br />1. NAMES OF STREET$ OR ROAD$ NEAREST TO UNDINa eaTHE PROPERTY. E. LOCATION OF HOUSE SEWAGE DIBPoDAL SYSTEM OR PROPOSED <br />2. 0UTUME OF THE PROPERTY, GMNO DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEM.. <br />SI <br />1. DIMENONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RARE <br />RADIUS Of ONE HUNDRED FIFTY FT. <br />STRUCTURES. INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS. AND WALKS. ON THE PnOPERTY OR ADJOINING PROPERTY, <br />DEPMTMENT USE ONLY <br />APPSe.11e.l A—," <br />D--I—I w—I- <br />D.I. q(_ lL Arr <br />o.I. <br />ACCOLMTINO ONLY: <br />I AUDI <br />I FACP <br />,o / R <br />(111M <br />P1 CODE& FEE TUFO <br />AMOLMT REMTT. C C NM <br />RECOVER DY DA E <br />PERMITISOME REOLJEST N M INVOICE <br />