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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 'I ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA Mall 88 <br /> (2091468-3420 .� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER D�� <br /> (Complete In TApH atel <br /> APPLICATION 06 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK OESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> f1 f <br /> JOS AODRE88fOR API# J71 I� (_�!1 [,.c [� CFly 41rT -1PARCEL SIZEIAPNifr.• <br /> Cn <br /> OWJNER'B NAMECAI <br /> ADbREBS4 1� r `J PHONE# <br /> CONTRACTOR 1' !t 11 ADbRE86L, a� UG#� PHONE♦•2W <br /> OUR CONTRACTOR ADDRESS LIC# PHONE• <br /> TYPE OF WELLIPUMP: 1I NEW WELL Cl REPLACEMENT WELL ❑ MONITORINO WELL# ❑ OTHER <br /> 44 ❑ INSTALLATION ❑ WELL YBTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> DJ�� ❑New❑Repair H.P. _ DEPT"PUMP 5ajj�jT• FIR4T WATER LEVEL p <br /> (TYPE OF PUMPI <br /> k ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING <br /> g <br /> ❑DEBTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION 'Fl! (CATIONS if A <br /> i <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION .__ DIA,OF CONDUCTOR CASINO D <br /> I DOMESTICR'RIVATE ❑GRAVEL PACKMIZE TYPE OF CASINGIBTEELIPVG ~r <br /> DIA,OF WELL CASING <br /> 11lNI ..77 p <br /> f PUSLICUNiCIPAi ❑DRIVEN DEPTH OF GROUT SEAL_"" _l COO � BPECIFICA7ION �'t ' 7 R <br /> ❑ IRMOATKINIAO ❑OTHER GROUT SEAL INSTALLED BY__- .� , _ GROUT BRAND NAME <br /> ❑ MONITORINGw j GROUT SEAL PUMPED: MY. ❑No CONCRETE PEDESTAL BYORILLER'�Vw ❑Ne 5 <br /> APPROX.DEPTH LOCKING CHESTER BOxisTOVE PIPE S <br /> PROPOSED CRNSTRUCTIONMRILLiN0 METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER J <br /> 1I <br />' I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE VITM BAN JOAQUIN COUNTY ORDINANCES,$TATE LAWS,AND RULES AND f'" <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING.-1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICHIrI <br /> T1418 PERMIT IS ISSUED,I SMALL NOT EMPLOY PERSONS BUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTINO 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'S COMPENSATION LAWS OF�"t <br /> CALIFORNIA.' THE APPPLIC NT MUST CALL 74 HOURS IN ADVANCE FOR ALL REQUIRED IN!ICTPONS AT IEOSI 4603435. COMPLETE DRAWING A7 LOWER AREA Pf10VIDED. ,(. <br /> Signed x 7.•L'3tfL Title '��, n �` (�1 <br /> Dat. <br /> •I� <br /> ✓t <br /> PLOT PLAN(brew to Scale)Seale to `> <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> Z. 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. QH THE PROPERTY OR ADJOINING PROPERTY, <br /> ,rA� <br /> f .... �:. kzr <br /> RJ <br /> k <br /> 4 ' <br /> .. r ?. <br /> J . <br /> f <br /> Y.A•l EN <br /> �QU <br /> JIM+Yo. Pt(�r <br /> F'lfE3Ll M SE ICES <br /> IMVIrroWir'i„ I tFAI.T I l+?IbISIOt r t <br /> DEPARTMENT USE ONLY j <br /> Applleetlon Aeeepted By Deis Z <br /> Grout Impaction By ILC<+�'>t� Date /�213 Pump Inspection By bete <br /> Oealrrrotlon Impaction By. <br /> Data <br /> 7F <br /> Ce—fa tw <br /> ACCOUNTING ONLY: AID# FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTEDECK ABH RECEIVED BY DATE P9tM1Tism%riCE REOUEBT NUNIsm INVOICE <br /> f DS 5 <br /> '�� 13 <br />