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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201.368 <br /> {209] 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplieatol <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED,THIS APPUCATTON IS MAOE IN COMPLIANCE WITH SAN <br /> JOAOMN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN <br /> (COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APN,f 6 f LL4 5/0 {0 oeiA��'eyee-- &-t,ty f l JCfTY f f.�e �Vv PARCEL SIZEIAPN/_ <br /> OWNER'S NAME�C: zib Oft d s•f 7 7r-t a o s- ADDRESS PHONE if _ <br /> CONTRACTORS �4- 61^ ADDRESS q�d LICK PHONE# :t f?/11L// <br /> � <br /> SUBCONTRACTOR CClf-Y](, PLAOORESS4�1 � yOl"t LILT —PHONE# <br /> TYPE OF WEIllPUMP: L NEW WELL ❑ REPLACEMENT WELL ❑ MONrrom G WELL Pf I OTHER _ <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR fL--J� VAPOR EXTRACTION WELL N r <br /> _ ❑New❑Pgpeir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> (TYPE OF PUMP) �,/_ / <br /> ❑ OIJT-DF-SERVICE WELL ❑ GEppHYSICAL WELL K SONI(J3/,fi IL BORI �'f�-� �AJ[� a <br /> 11 DESTRUCTION: Z/ ff//f e-y u) <br /> INTENDED USE TYPE OF WFJ_L 2ONSTRUCTION SPECIRCA.ONf // rI A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION (C� I DIA.OF CONDUCTOR CASING O t` <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACiUSIZE TYPE OF CASINGISTEELIPVC T DIA.OF WELL CASIN43 D <br /> ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SP•@CIFICATION �/1/✓� R <br /> ❑ IRRIGATIONlAG ❑OTHER GROUT SEAL INSTALLED BY 'SROUT BRAND NAME--T E <br /> ❑ MONRORINO �J r GROUT SEAL PUMPED: ❑Yee ❑Ne CONCRETE PEDESTAL BY DRILLFR:❑Yea ❑No 5 }� <br /> APPROX.DEPTH LACKING CHESTER BOXIUTOVE P(PE 3 yywvv <br /> PROPOSED CONETRUCTLONIDWLLINEO METHOD: MUD ROTARY ]A[ AIR ROTARY AUGER _CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL PIE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLW.VMNG:`I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THM PERMIT 1S)SSIJED,I SHALL NOT EMPLOY PERSONS SUBJECT YO WORKMAN'S COMPENSATION LAWS OF CAUFORNHA CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIE6 <br /> THE FOLLOWING: I CEKTIFY THAT INT FIFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SH/JL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFDRNIA.' T MUST C'�4W ADVANCE FOR ALL REOURED INSPECTIONS AT[20814M,J423• COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slened X Title ir,l�+c+L OeCe <br /> PLOT PLAN(Draw to SrLsla1 S"Ia <br /> 1. NAMES OF STREETS OR. TQ Oft BOUMNG THE PROPERTY, 1, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPE •„01VINIG OIMEtWONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONED OUTLINE$'AAND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS VVrrMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANG WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> AMHCR51 IIT <br /> HAVAIER <br /> ROCf FCRD AV MACRONE AVE <br /> RICH TAMARISK AYC <br /> SUMAC PVF <br /> CI <br /> Grupe \fs F CYPRESSA ,t1 <br /> c ',� ox,lvi, AY <br /> ��nE t 11 c M_f In l'TEAU s MAN7ANITA - <br /> ' au <br /> ;� PWT i IASMINE �Lake1 1MnNEI �;eurronwntowLIGHIii(SUSE4Ia�a IRCx JCl i SOM EBAD31I f j, ` I R HAZELw000 AV - <br /> SCHOONERD <br /> .-- <br /> WICHi Rs <br /> vs Rymoul <br /> ..., y ` Ck } l1EV.��j ori+ MAL EN <br /> e <br /> CT — <br /> EXEC <br /> a mM,t T. ! UTYVE <br /> l o�+ 4,,01 ¢ WHIRLER I GOLF COURSE - <br /> zr PR ATLANTA 9 -t p L <br /> 1 UH <br /> 4ORTH WATER _ aluvr <br /> �15�11 µp!l[rtA <br /> ... ... .... .... '_ � CPP. <br /> ry CONTROL PLANT I c I {, �I pn Cure KC <br /> I m }tC}F p d Etlll N - <br /> .*C' OR <br /> } $II FIVE EDRKS <br /> ;RfGHT TRACT) S rl a = C1'' <br /> �I s <br /> ft <br /> a.. � , J � tixu�n sWENSgN MUfv1ClPf4 <br /> { <br /> y - <br /> o �.� l:°; <br /> ' OUASF <br /> -. ...... f �F• 4,. GOLF c <br /> i <br /> wayHl - <br /> - -.- <br /> � <br /> 9EN� <br /> �:r K rcifl* SWRMAN <br /> - ; ,- - - - .. o.,n�m wrl.-. 5• l� �- nun — t ' <br /> DEPARTMENT USE ONLYApplication AcceptedBy�6u DV/�Jate ! 5 Arse <br /> Greet Irlepectlan By baro Pump Impaction BY Data <br /> Destruation Inspection By_ a x�yt.— _J Data <br /> Comments: �, 0 ✓ / !O fr0asi-- <br /> C�. 4r fie f r[ 9(Q <br /> ACCOURTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC 1t ASH RECEIVED BY DATE POMTISERVICE REQUEST NUMM INVOICE <br /> 1221z das��7 <br /> b� � 1 <br />