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a <br /> y APPLICATION FOR WELL►PUMP PERMI' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEh,,., S <br /> i ENVIRONMENTAL HEALTH DIVISION I L�/�2 /P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 2,��f <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSIALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT 3 1 S /_TITLE, <br /> ^ P CHAPTER 9.11 1 5.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESS/OR Apw# 3/J 1 Ct7 rrok PIP c/ CI Jsly --'Lyo N PARCEL SIZE/APNI <br /> OWNER'S NAME CeCdl i,v1i. ceCG It 1),f' -" 6-7?1✓a floct-t.(, fI ` / �'j / -7 <br /> ADDRESS J I ZI `�-57 f'l�/1�ec lel PHONE I_ <br /> LLIIIjr— � L I��Ui'ZL 1 6LnoonEsa 7gZ _f ly�trf ��ZZ� PHONE <br /> G RACioR -��P CTS 7r!J/19 p �t UCM� <br /> }r�J,V'yI TRA 6 �-- ADDRESS f l/.S C7' .J CR PHONE IJ U-fib ��✓+ <br /> �tl8 <br /> NT MCTOR_ ��.S�- _ <br /> TYPE OF WELUPUMP: EW WELL ❑ REPLACEMENT WEU. MONITORING WELL I V�/ Z ❑ OTHEn <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑CnOSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLN j <br /> TTYPE OF PUMP( 1:1 Now❑F%P.lr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL R ❑ SOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL C0N6TRVCTI0N SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 0 <br /> ❑ DOME8TIC/PRIVATE GRAVEL PACK/SIZE TYPE OF CASING/6TFFIJPV//C__ DIA.OF WELL CASINO_.[ Z/ p <br /> ❑ PUBUCMIUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_J(!O .�-�y' SPECIFICATIONSC/7 R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED By S,��c//V tY^1 GROUT BRAND NAME F <br /> MONITORING / GROUT SEAL PUMPED: ❑V..�f70 �!KT't^-� CONCRETE PEDESTAL BY DNLLFR:O'Yw ❑No S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 4o ck'7(.6 F�v`'S h—n'1(�c{ S <br /> PROPOSED CONSTRUCTION/MLLINO METHOD: MUD ROTAnY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT 1 NAVE PREPARFD T1416 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF TILE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF TILE WORK FOR WHICIt <br /> T1416 PERMIT IS ISSUED,i SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIER <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WINCH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' HE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 12091469-2423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> glared X �- //•f 6 � <br /> F-^-� PLOT PLAN IDr to ar,Mel Sc.le 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 0. 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 WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> �f <br /> .... _:. . <br /> FISC EVE <br /> 4.E <br /> DEPARTMENT USE ONLY <br /> Appll—ft.Accepted By Got. Are. <br /> Orevt Irwpeetlon By D.t. Momp Imp.etlen BY not. <br /> G_Iructl.n Iner—,: -Rv <br />