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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 /> (209)488-3420 <br /> NON-REFUNDABLE PERNT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Conploto In TRIPButol ^T <br /> APPLICATION IS HERE BY MADE TO TIE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED'.THIS APPLICATION 18 MADE IN COMPUANCT WITH BAN <br /> JOACUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.111 S.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESBIOR APNI J. ���\�\q� CITY <br /> FCS 1\L-�O\�] PAAC�t SgE/AP}IE <br /> OWNER'S NAME fit'\`I'1\ ��Q�T� ADDRESS I V.�OY 3 V t9� \ ^ PHONEQD O(�. <br /> CONTRACTOR LAN\V 2rS`ca� V`Lv�C� ADDPESa ��31.Q N.�cD►Y�\Al'�4 UGaylS _\ PHONEl\AQy `�l <br /> BUS CONTRACTOR AGGRESS LIC/ PHONE/ <br /> TYPE OF WEUJMMP: ❑NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑OTHER o <br /> �l ` RRR�BBB INSTALLATION ❑WELL SYSTEM REPAIR Cl CROSS-CONNECT REPAIR Cl VAPOR EXTRACTION WELL J <br /> l�Cl tAL Non 11R-1, H.P.�� DEPTH PUMP SETNV FT. FIRST WATER LEVEL o V T <br /> TYPE OF;a PJ / O <br /> ❑OUT-0FSERVICE WELL ❑GEOPHYSICAL WELL I ❑ SOIL BORING '- S <br /> ❑DEMVCTION: <br /> INTENOEU USE TYPE OF W[LL UCTION SPECIFICATIONS 1` , ! A <br /> INDUSTZ OPEN BOTTOM DIA.OF WELL EXCAVATION C� `^�, DM.OF CONWCTOR CA8N0 D <br /> TI DOMEMIC/PUVATE .NIVEL PACKISIZE TYPE OF CASINO/STEEL/PVC :-S L DIA.OF WELL CASINO <br /> 0 <br /> Cl PUBUCAAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION Raj <br /> ❑IRRIGATION/AG ❑OTHER OROUT REAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONITORNG I GROUT REAL PUMPED-❑Y- ❑N• CONCRETE PEDESTAL BY DRILLER:❑Y- ❑NeCA <br /> S(O <br /> APPROX,DEPTH LOCKING CHESTER BOXMTOVE PIPE S <br /> PROPOSED CONSTRUCTIONIDISWNO METHOD: MUD NOTARY AIR ROTARY AUGER CABLE OTHER <br /> — <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUN COVNTY ORDINANCES,STATE LAW",AND <br /> RULER AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOO(FOR WH,•ITE� <br /> THIS PERMT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTINO SIGNATURE CETTti3. <br /> THE FOLLOWING: 'I CFRTTFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF <br /> CWTOIMAA.' THE APPLICANT MUST CALL 24 IIOIIIU IN ADVANCE F-011 ALL REOlKRAT;"Ill 440�231, COMPLETE DRAW NO AT LOWER DAA APROVIDED,\—Z, <br /> �Tills \ l 1 <br /> PLOT PLAN 10—to"W.1 Sul. 'to <br /> 1. NAMES OF SPROPERTY.TREETS OR ROADS NEAREST TO OR BOUNDING THE PPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PNOPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANOION OF SEWAGE DIBPOBAL SYSTEM". <br /> ]. DIMENSIONED OVTLNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS VRTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING P DfUTTY. <br /> Q <br /> o � v <br /> 4. <br /> dl 9 <br /> fl <br /> TQS t C <br /> l\� <br /> PiWWN 1 <br /> MAR 19X91 <br /> .�NN JOAQL11 IV C.LJl IJ <br /> e <br /> PUBLIC HEALTH sERVICEb <br /> a <br /> LNV!RGtuM#N AL I,Er1LT!, <br /> OFPAATMFTIT WE ONLY _ Q L <br /> ApPllyllon Aocepl•a By D•1 <br /> Growl I: P_mt BY Dote P_f-p—-BY <br /> Ostr�clbn IrwP•oSo�eY D•1• <br /> Cemme w <br /> ACCOUN71NO ONLY: AOI FAG! <br /> PE CODES AMOUNT REMITTED g..51A:ABH RECEIVED BY DATE PORMITISDIVICE REOUPAT NUMBER INVOICE <br /> 3 0 - l.iL1(- ' A-,, G a(F 9I <br /> (g15(o <br />