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Lb APPLICAIION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, M BAST WEBER AVENUE", STOCKTON, CA <br /> (209} 4BB-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Cimplib IR TTip{iesei} <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 11$.3 AND THE STANDARgP OF,¢AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADDRESS/OR APNI Al'OFA <br /> CIYY ✓I� <br /> PARCEL S17tIAPNN� <br /> OWNER'S NAME <br /> ADDRESS 9,2170 F. j, PHONE ar !1 <br /> � -2 <br /> CONTRACTOR ADDRESS C7 r LICl PHONE <br /> SUB CONTRACTOR <br /> ADDRESS L1C>F <br /> PHONE! <br /> TYPE OF LL/PUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CFtOSS-CONNECT REPAIR <br /> � 1:1VAPOR EXTRACTION WELLS <br /> � J <br /> �+ - ❑Naw❑Repelr H.P, DEPTH PUMP BErFT. <br /> RYPE OF PUMPI FIRST WATER LEVEL_�a*�� <br /> O <br /> © OUT-OF.SERVICE WELL ❑ GEOPHYSICAL WFLL s ❑ BOIL BORING e <br /> ❑DESTRUCTION: - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION iPECIFICATIONi <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM - A <br /> DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING— O <br /> DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STFELA'n/C <br /> ,,r�yy DIA.OF WELL CASINO O <br /> ❑ PUBLICIMUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL V 8PECIFICATION_,. Jin R <br /> ❑ IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY _'� GROUT"RAND NAME <br /> ❑ MONITORING GROUT SEAL PUMPED:,m Yee [IN. CONCRETE PEDESTAL BY DRILLEFIy ❑Ne S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE FMPE S <br /> PROPOSED CONSTRUCTION11MLLING METHOD: MUD ROTARY AIR ROTARY AUOER CABLE OTHER <br /> I"MBY CERTIFY THAT I HAVE PREPARED TMS APPLICATION AND THAT THE WORK WILL 8E DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,SLATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'t CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'$HIRING OR SUB=CONTRACtING SIGNATURE CEFITIFIE91k <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERPORMANCE.OF-THE WORK.POR WHICH THIS PERMIT IB 18SUED 4 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF� <br /> CALIFORNIA.' THE LICA MUST CALL 24 NOV$$IN ADVANCE FOR ALL REQUIRED INSPrTIONi At 12001 4MJ423. COMPLETE DRAWING-AT LOWER AREA PROVIDE . <br /> stanaa X �f- <br /> TItIa , <br /> — � Date <br /> PLOT PLAN{Drew to Scelel Scels 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR 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 /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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 /> z <br /> A it <br /> (1 ()Q 7.�. <br /> ENI <br /> AUG 2.9 1991 <br /> _ i SAN JOAQUIr <br /> .OUN7y <br /> FAvlcrs. <br /> cr .DIVISION <br /> DEPARTMENT USE ONLY <br /> Appllcatlon Accepled By 0 Z �� <br /> p a'"7 <br /> Grout Irnpmtlon By Det. + a g7 Pump InrpsQpetlon By. Onto t a ! <br /> Dmotrtntlon Inepactlon BY <br /> 1 ` beta <br /> f <br /> Cemmente;_ LtJGfr' YDr�S1f !a O`� �L/JLf A 14 3ESTm`�[��l <br /> ACCOUNTING ONLY: AID# FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED (—CH ItCK�ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> -& �' O 1�1 X03 <br /> SG `f d a�fl b <br />