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APPLICATION FOR WELLIPUMP PERMIT <br /> { IAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES F <br /> r� ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 3M TA EAST WEEIER AVENUE, STOCKTON, CA 95201-388 +SIF <br /> {209) 488-3420 fl \`�f <br /> V <br /> NON•REFUNQABLE PERIMIT <br /> EXPIRES 1 YEAR FROM QATE ISSUED <br /> APPLICATION IS HERE 8Y MADE TO THE <br /> IC InPleta In Triplicate) <br /> SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND10R INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE hWITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. II <br /> JOB ADDRESSOR APNN��J Q .sn- CITY �✓..Q.j.1-moi <br /> O /� PARCEL SIZEfAPNN <br /> OWNER'S NAME - 6 + r ` <br /> ADdAE88 �J Q ONE N <br /> CONTRACTOR Ct Hwti ADDRESS LCt I �� r <br /> I b .�y� PHONE/ 96 Zs <br /> r SUB CONTRACTOR ' <br /> it ADDRESS <br /> LICN �PHONE 0 �S <br /> TYPE OF WELL/PUMP: ❑ NEW WELL '� ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ' <br /> c ❑ INSTALLATION 13 OTHER <br /> .i ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f <br /> V uL 11 Naw❑Rapdr II H.P. �- I J <br /> OF PUMP) <br /> DEPTH PUMP SE7FT- FIRST WATER LEVEL <br /> U <br /> ❑ OUT-OF-SEVICE WELL ❑ OEOPHYSICAL WELL N ❑ 80tL BORING <br /> ❑DESTRUCTION: 1 8 <br /> INTENDED USE TYPE OF WELL CON6TpUCT10N 6PEClgCATIONa <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM 3Y A U� <br /> �� 01A.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOlSTEEIJPVC �` F 00 <br /> i ❑ PUBLICMIUNICIPAL ❑DRIVEN DIA.OF WELL CASINO I, v <br /> DEPTH OF GROUT SEAL SPECIFICATION h <br /> ❑ IRRIOATIONIAO ❑OTHER GROUT SEAL INSTALLED BY R 1--. <br /> ❑ MONITORING 'i �. GROUT BRAND NAME E <br /> GROUT SEAL PUMPED: ❑Yw ❑Nn CONCRETE PEDESTAL By DRILLER:❑Yea APPROX.DEPTH - No <br /> LOCKING CHESTER BOXMtOVE PIPE E <br /> PROPOSED CONSTIIUC710N1OR1LIJNG METHOD: MUD ROTARY AIR ROTARY Sr <br /> AUGER CABLE OTHERI" <br /> I HE by CERTIFY AT I HAVE EPAREO THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES fi <br /> REGULATIONS THE SAN JOAO IN COUNTY. H ME O R R LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'!CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHlCH�Q <br /> THIS PERMIT I SSUED,1 SHALL T EMPLDY PE BJEG TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFlESll'"�; <br /> THE FOLLO G: i CERTIFY TIN PE E OF HE WORK IGH 7H R IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF* <br /> CALIFORNIA. TH VAT CA CE REQUIRED Na <br /> .i R( ►!4p,�{22, COMPLETE DRAWING AT LOWER AREA PROVIDED. 'E <br /> Slpnad X ��/J <br /> ' Title �A.,1 <br /> Date �• <br /> ` PLOT PLAN[Draw to Body so dsfm y ¢ <br /> E 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPDSEO <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> STRUCTURES,INCLUDING COVERED AREA: SUCH S PATIOS,DRIVEWAYB,,ANp WA[K8. E- LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY fT.' <br /> - _ --. ..,;..............: ..._.....;. PRO <br /> ON THEPERTY OR ADJOINING PROPERTY, <br /> 3 <br /> . <br /> KAY 2.. <br /> _ B C'HEAL <br /> ,> l uN fi�T <br /> �I� u ,dGE <br /> S <br /> I FtI fit I- H0.1vislCI <br />- �-.:�!-�•'-'i.•w+.�....�.-:+ems: : a�w.�..i�'�. r--..^jt� i�wr'9Ylacea«- �w^'� - ylY...: +-+�'�'wr' <br /> .... : ... <br /> t.. <br /> DEPARTMENT USE ONLY <br /> Application Aoeepted By <br /> Date <br /> Moe � <br /> dreut Irgpectlen By � � Date C\ <br /> I P InaPeotlon By Date-7—9r <br /> Destruction lrrpaollen By �? <br /> Cemmenta: Date <br /> II <br /> pp I <br /> Lr AL ACCOUNTING O Y: AIDN 1 <br /> FACT <br /> PE CODES FE F h <br /> AMOUNT REMITTED EC MAS RECEIVED BY DATE <br /> PERIY ITISEHVI E REQUEST NUMBER INVOICE <br />