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X0.5 0y <br /> APPLICATION FOR WELLIPUMP PERMIT r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV.. °S C <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 3W304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 4883420 ////���� <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED 'FII <br /> (Complete in Triplicate) <br /> APPLICATION IS HENS BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED.THIS APPU IS IN MPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TTIL/IT�LEE.)CHAPTER 9-1115.3 AND THE ANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOBADDRESS/OR1APN/11 dPVEA <br /> CITY­LO dC ( O �PARCEEL SIZEIANI <br /> OWER'S NAME e- rTd FaIrms ADDRESS 94/00ArA4Ie/D124PHONE# <br /> CONTRACTOR -VQ fTGiRAM <br /> � <br /> LICI PHONE#4,062. <br /> 3 <br /> SUB CONTRACTOR ADDRESS UCl PHONE <br /> TYPE OF WELVPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNE T EPAIR ❑ VAPOR EXTRACTK)N WELLJ J <br /> Tu*-&n ee ❑N.❑Re , H.P. DEPTH RUMP 6E �T., FIRST WATER LEVEL 0 <br /> RVR OF RIMP <br /> ❑/1OUT-0E-\SERV�I/C�E W�E�LfL ❑ OEIL GEOPHYSICAL WELL/ ❑ BOBORING <br /> ,/�// B <br /> INTENDED USF TYPE OF WEtl CONSTRUCTION SPECIFICATION{ A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/RU VATE ❑GRAVEL PACK/SIZE TYPE OF CA61NGMTEELJPVC DIA.OF WELL CASING D <br /> ❑ PIIBUCBJIUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION N <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F <br /> ❑ MONITORING GROUT SEAL RUMPED: Ely. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y. ❑Ne 5 <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE 5 <br /> PROPOSED CONSTRUCTIONRDSWND METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERT THAT 1 HA EPABED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANL <br /> REGULATIO OF THE SAN JOA IN COUNTY. HOME O R LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICI <br /> THIS PF IB ISSUED,1 SHALL T EMPLOY PE NS BJ T TO WORKMAN'{COMPEN{ATOM IAWe OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB{ONTRACTING SIGNATURE CERTIFIEI <br /> THE FO WIN..... <br /> : 'I CERTIFY IN TN NC F THF WHICH THIS PERMIT IS ISSUED,1 SHALL EMROY PERSONS SUBJECT TO WORIQEAN'{LOMPEN{A110N UWB O <br /> CALIFO IA.' TNF T URL VAN FOR ALL REOUMED(1 OM{A/T],/1Fj//q//Y)�4q,/J�t3/f�. C�OM�R�ET/E/DRAWING AT LOWER AREA R)U VIDED/., �j�J <br /> 6lprre X ra Title `�V ///l Flt//✓�^-CNV Dete GL�t/L� / / <br /> PLOT RAN IDI.w to Soel.l Sulo Le <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 SY6TEM8. <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 WALK$. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> IY <br /> I <br /> fir• <br /> b <br /> C ® b <br /> . - - - �u9cIC HEALTH ERbIC�.E <br /> IJ J aCNl.hFh 1:{1l,.H.EA1 <br /> 'IF",Y <br /> Application Accepted BYI Data J A,. r <br /> Gmu1 Impectlon 81 to Pump Inspection BY ON 7-,/ <br /> Destruction brpectlon BY Data <br /> Comments: <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE COD" FEEINFO AMOUNT REMITTED CHEC (CASH RECEIVED BY DATE P ITISERVICE REQUEST NUMBER INVOICE <br /> 03577✓ <br />