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4PPLICATION FOR WELLPUMP;.PERM'- !. <br /> SAh "OAOUIN COUNTY PUBLIC HEALTH SE DICES P) <br /> '-ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> f <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TripDeftf) ,I <br /> APPLICATION IS 14EM BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMA INSTALL THE WOW DESCRIBED,THIN APPLICATION IS MADE IN COMPLIANCE WTIN SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH Mn"CES,ENVIRONMENTAL HEALTH IRMSION. <br /> JOB AODRESSMR APHI p-��+" �I G" U f <br /> CITY �Lr'��� PARCEL SIZE/APNI <br /> /� �^ C <br /> OWNJ_L"'�ER'S NAME Y, l c�fS 1 (\ n 1`I _ ADDRESS_�( t ( \ ,1, .1 �11.1�Q(Y -tVJ"l?C b110NE I���1�g.3)- 4I to <br /> ADDRESS_�. _ ^ —uTn <br /> LO PHONE Cly <br /> .`} <br /> SUBCONTRACTOR�y1c�C_�'(uyYl �X(�lor•nt'G.(� ADDRESS LGSIW;C�LAi CLYYI I..II�'lIC/�( a�GJ FHONE 13 C� YvtJ �7/. <br /> TYPE OF WELVPUMP: 111❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONDORINO WELL 1 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR'? ❑ VAPOR EXTRACTION WELL I J <br /> 11N.0 R. .I, N.P. DEPTH PUMP SET_FT. •i FIRST WATER LEVEL O <br /> RVIE OF POMP f <br /> DESTRUCTION' <br /> ❑ OUT-OF-SERVICE WELL ElMOPHYSICAL WELL /I �I SOIL BORING 10 N <br /> ❑ <br /> II` - ' <br /> INTENDED VSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM OIA.OF WELL EXCAVATION li OIA.OF CONOUCTORCA6,Np O <br /> ❑ DOMESTICIRUVATE ❑GRAVEL PACK/SIZE TYPE OF CA61NOISTEELR'VC DIA.OF WELL CASING D <br /> ❑ WBLICRAUNICIPAL ❑ONWN DEPTH OF GROUT SEAL <br /> SPECIFICATION <br /> R <br /> III <br /> ❑ IMIGATIONIAG ❑OTHER GROUT SEAL INSTALLED Y ( GROUT BRAND NAME P <br /> ❑ MONITORING GROUT SEAL PUMPED:VA'r [IN. I) CONCRETEPEDESTALBYORMER:❑Ye. [IN. S <br /> APPROX.DEPTH LOCKING CHEBTEn BOX/NTOVE RPE S <br /> TIV <br /> PROPOSED CONSCTIONIGIBWNG METHOD: MUD ROTARY AIR ROTARY AUGER '� CABLE OTHER YLI.:"k- 1(�4.SI <br /> II <br /> I HEREBY CERTIFY THAT I IIAVE PREPARED THIN APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER On LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE MAK FOR WHICH <br /> THIS PERMIT IS ISSUED,I911ALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB.CONTMCTIM SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE F THE WOIK FOR WHICH THIS PERMrT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA. APPLICANT MUST CALL XA IgllRf IN V RACE FOq ALL REOUREDD INSPECTIONS AT <br /> lLEON)409J 20. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 61Pmd%_ 1 , ,la_/1_A-1 am T10. <br /> MOT PLAN(Drµto SeY.1 S.N. 'le <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOU9mNO THE PROPIATY. �y 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PmPO6ED <br /> 2. OUTLINE OF THE PROPERTY,OMNG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENI PONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED .� 8. LOCATION OF WELLS WITHIN RAOIUS OF ONE HUNDRED FIFTY P. <br /> 6TRUCTVRES,INCLUDING COVERED AREAS SUCH AN PATIOS.DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> y <br /> DEPARTMENT USE ONLY <br /> APp11c.Ibn Aee tp BY ILA t,C/\ { D.t. Z Mw <br /> Or.ul Impedlen BY nnA!`r/\ Da.�J Z 0 Pune Imp,cSen BY II Dae <br /> DmInsllen ImP.etlon By SII D.Is <br /> Cemmemr <br /> I� <br /> ACCOUNTING ONLY: Am/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKIICABN RECEIVED BY GATE ?[ IMMOTISE6VICE REQUEST NUMBER INVOICE <br /> S O OD 2 i <br /> ld b0 S <br /> 'f <br /> .E <br /> Pub.Health SEN.-Enviro.173(1197) li <br /> ;V <br /> I� <br />