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APPLICATION FOR WELUPUMP PERMIT <br /> . SAN JOADUIN COUNTY PUBLIC HEALTH SERIM <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 96201-388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICampuu in Triplieeul <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TIRE.CHAPTER 9-1115.3 AND THE STANDARDS OFF�S.,ANN JfOAQUICOUNTY C HEALTH SERVICES,ENVIWNMENTAL HEALTH DIVISION. <br /> J00 AODREGBR]�PN# '�'-7"'TT'f �. Pf�TTa..y T� oP^R(��1W FLY CffyYyA 1 PARCEL SIZE(APN# <br /> OWNER'S NAM AQ <br /> I�+�u �gppREBb -PH <br /> CONTRACTOR <br /> y /-' ADDRESS 33G ��LICY R10NE41 �FC��37�1��13a <br /> SUB COMMCTORTT--ppr/ ADDRESS UC# PHONE#— <br /> TYPE OF WELLIPUMP: y�NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL y❑3 OTHER <br /> ❑``INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSLONNECT REPAIR YJ VAPOR EXTRACTION WEILL 1 D�`I�291 <br /> ❑NPN❑Rooa' H.P. DEPTH PUMP SET—FT. „FIRST WATER LEVEL 71 V/ O <br /> TYPE OF PUMP <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPIYSICAL WELL# ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING_ D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/ C DIA.OF WELL CASING y403,-A D <br /> ❑ PUBUC/MUNICWAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION 111',^, 1 R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME flf+W L <br /> KMONITORINOY / ^ GROUT SEAL PUMPED:JWYaii ❑Ne CRETE PEDESTAL BY DRILLER:❑Vs ❑Na S <br /> APPBOX.DEPTH (K_ LOCKING CHESTER BO%ISTOVE%PE RI S <br /> PROPOSED CONSTRUCMON/DAWNG METHOD: MUD ROTARY AIR ROTARY AUGER--x1— <br /> UGERx CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MTN SAN JOAGUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPS GATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF <br /> CAUFORNIA." THEA CAN��99T Ll T C M HOURS IN ADVANCE FOR ALL REOURED INSPECTIONS AT 12010*109i 22. COMPLETE DRAWING AT LOWER AREA PROVIDED. f <br /> slgr X ((.1/Lep .e2 TIB. <br /> PLOT PLAN IDrw to S.N.I Sole to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. i. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM 00 PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. 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.DRIVEWAYS.AND WAU(S. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ... ....r_. ...... .... ... <br /> Ij ..._.f. . ..J .....'. o . ....w.. ....I. .a.. ...... i_..... ...._. <br /> DEPARTMENT WE ONLY <br /> APPlle.nen AeeeptM ny D.t. bb A— <br /> Grout IrspPum <br /> ..tl.n By Dna p I.ostl0n By Dae <br /> Ds.,I.n Ir ostl.n < D.ro <br /> C.mmmu: <br /> ACCOUNTING ONLY: Ami FAC# <br /> PE CODES FEEINFO AMOUNTREMITTED CNEC"XASH RFLnVm BY DATE PEIMNT/SERVICE REQUEST NUMBER INVOICE <br /> SO 1� lti1 3�i <br />