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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 96201388 <br />(209) 468.3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />APPLICATION IS HERE By MADE TO THE SAN JOAOUIN COUNTY FOR (CemPleA PERMIT TO CON6TRV„Thn Trok N1el <br />DIOR 6TALL THE WOO( DESCRIBED. THIS <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 ANDTHESTANDARDS OF SAN JOAOUIN COUNTY PUBLIC <br />APPLICATION 18 MADE (DIVISION. COMPLIANCE WITH BAN <br />HEALTH SERVICES, ENVIRONMENTAL HEALTH <br />JOB AODRFSSbR APNI Or [)G✓CI'R (C (1!U Ip �l(/ F m[ y- 1 '/ LL <br />/'Si CRY._.Stclrk <br />1 n UI,' 7iil PARCELSIZE/APNI T �^ <br />OWNER'S NAME PP f!✓ 2✓/l k,, Me ! �f R[in ADOREgB ��// SlvnC B lV!/ <br />,1 5!1 E I Amf n PHOONE 0 <br />CONTRACTOR EC//21Ln C( �L_ /TryA /T �h C , <br />SUB CONTRACTOR ry �/ �CU , SlUc k n C/ �) <br />J" ADDRESS /lJTG LIPIgNEI U - J <br />'I <br />.T <br />ADDRESS UC/ PHONE/ao9 <br />M/ I <br />TYPE OF 1 UMP ❑ NEW WELL ❑—CEMENT WELL ❑ MONITORING WELL <br />/ ❑ OTHER <br />❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS -CONNECT <br />REPAIR ❑ VAPOR EXTRACTION WELL / ✓ <br />❑ Nwv ❑ RePNr H.P. <br />RYPE <br />DEPTH PUMP SET <br />OF PUMP _—FT. FIRST WATER LEVEL <br />\ <br />O <br />pj A / OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL / ❑ BOLI BORING <br />W I IrC V!`C l!I(�'L/ ( (� <br />DESTRUCTION: w / '/ S / /,� S <br />!r /'V& INL /I <br />1 C/!1N <br />INTENDED USE TYPE OF WEu (do, 16 rca6 <br />❑ CONSTRUCTION SPECIFICATIONS <br />INDUSTRIAL OPEN <br />N BOTTOM <br />dA. OF WELL EXCAVATION A <br />pp❑FR <br />❑ DOMESTIC/PIVATE ICFGRAVEL PACK/SR/; TYPE <br />E C2DIA. OF CONDUCTOR CASINO <br />O <br />r� <br />OF /SfEEL/PVC '—_ <br />❑ PUBUC/MUNICIPµ ❑DRIVEN dA. OF WELL. CASINO <br />DEPTH OF GROUT D <br />T SEAL <br />❑ IRRIGATION/AG ❑OTHER SPECIFICATION <br />GROUT REAL INSTALLED By GROUT BRAND NAME G <br />/- \'' <br />✓Urp R <br />MONITORING�7 / <br />GROUT SEAL PUMPED: ❑yr ❑Ne E <br />APPROX. DEFT N / .S CONCRETE PEDESTAL BY DRILLFR: ❑ yr Ne S <br />�\J` <br />PROPOSED CONS711UCTION/DPoWNO METHOD: MVD ROTARY LOCKING CHESTER SO%/STOVE RPE <br />AIR ROTARYS <br />AUGER_ CASLL OTHER <br />1 HEREBY CERTIFY THAT I HAVE PREPARFD THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COU MY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE BAN JOAOUIN COUNTY. ROME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I <br />THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY <br />CERTIFY THAT IN THE PEgfORMANCE OF THE WORK FOR WHICH <br />PERSONS SUBJECT TO WORKMAN'S COMPE}ISATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING E BUBLONTRACTING SIONATURIE CERTIFIES <br />THE FOLLOWING: • 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL <br />CALIPORNIA.- THE APPJCA/N7 MUST CALL <br />EMPLOY PERSONS RU ECT TO WORKMAR'S COMPENSA710N LAWS OF <br />21 HOURS IN AgyANCE FOR ALL REQUIRED IN�JTI—TION' AT 1-1 MS -22. COMRETE —WINO AT LOWEFIA REA PRO <br />VIDEO. <br />111 ­nn. %IUI�c.f �iP�/us 13 D.I. 8L9�9S <br />PLOT RAN IDT I. Sinal Sul. / <br />1. NAMES OF STREETS OR ROADS NEAREST Toll BOUNDING THE PROPERTY. ro CI <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAU(S. E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY rr. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />r, y Itii <br />F .. <br />ANSI <br />.. .:... <br />DEPARTMENT USE ONLY <br />A"11-11- A -",l By <br />D.Le CLX ly <br />Orou1 IrrprHon By J /I Arr <br />D., r <br />P—P I -P.11- By <br />DrhuoHen In.prHon By O.Ls <br />D.la <br />Cemm.nt.: <br />ACCOUNTING ONLY: AID( <br />FACT <br />DFIA <br />�'O�e <br />IFIEE'INFO +-w3V CT.(OICE <br />