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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> See (2091468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete IN Triplicate) <br /> ea, APPLICATION IS HERE BY MADE TO THE SAN JOAMN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TIRE,CHAPTER 0-1116.3 AN E STANDARDS OF SAN JOAOUIN COUNTY PUBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH OMSION. Sett N•' <br /> �7 ' �M <br /> JOs ADOIIEB&OR AP/N �p GC. P L cm {//�1�N PARCEL SIZEIAPNI /9S�3J1^9- '��24 2- <br /> See <br /> See TT ` Pip ADDRESS P_D J-�(/r1C P C� �T:J✓—�]C�L <br /> OVAVER a NAME[ ///Y�I� ` x,/ v1 ,�j ( �1 / PHONE <br /> CONTRACTORAa�1/� I�1,••L[/I' ADDRESS / L�1 F-t I6•P✓`S KN /�ll�e`/. PHONE&5 <br /> BUB CONTRACTOR �� ADDRESS Me PHONE e <br /> TYPE OF MLLNUMP: ❑ NEW WELL �,I3HFLA: M WELL 1:1MONITORINO WELL e ❑ OTHER <br /> ❑ INSTALLATION ❑ WELLS': TEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL e J <br /> ITYFE OF PUMP? 11New❑F. .I, N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ❑ OUT SERVICE WELL ❑ GEOPHYSICAL WELL i ❑ SOIL BORING S <br /> L - c <br /> ❑ Q L( <br /> DESTRUCTION: �(f L()0— I !K D 11 A L 1 1 C i h W�a �.1 ,-, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIRCATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Y DIA.OF CONDUCTOR CA&NO D <br /> �aQPMESTICA'WVATE 4a4MVEL PACKRKZE TYPE OF CA&NO/STEELIPVC DIA.OF WELL CASINO /� e� O <br /> - ❑ RIBLICRAVNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER Ci C-1-.d ASL_ GROW BEAL INSTALLED BY t C GROW BRAND NAWJkl <br /> O E <br /> MONITORING <br /> APPROX.DEPTH ©© ( GROUT SEALPUMPELOCKING CGHER BOPIPE❑N.X/STOVE CONCRETE PEDESTALS Rl1ER:❑Yr '-�aL^ S <br /> PROPOSED CONSTRUCTION UJNO METHOD: MUD ROTARY_AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE GONE IN ACCORDANCE WITH SAN"AMIN COUNTY ORDINANCES.STATE LAWS,AND HOLES AND <br /> REGULATIONS Of THE SAN!GAMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PEPEORIAANCE OF THE WORK MR WHICH <br /> THIS PERMIT 16 ISSUED.1 SNAIL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CIAT11ES <br /> THE FOLLOWING: •I CERTIFY THAT N THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA." THE APPLICANT MUST CALL 24 HIMPS IN ADVANCE FOR ALL RMU RFD INSPECTIONS AT(2/S14011i422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> sl, W X 110, j,v—je Y TRI. N N F'I1�FL GM. <br /> PLOT PLAN B31.w 1.S .)6 1. •t. <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 OUTUNF6 AND LOCATION OF ALL EXISTING AND PIOMSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCHi AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> /* <br /> IN <br /> s v <br /> . ( JUN 2 4199.6 <br /> _ SAN JUACtc.iN 4vU,'v 1 <br />