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APPLICATION ,FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAOUTAI ST., STOCKTON, CA 96201388 <br /> (209) 4683420 <br /> U0a I�`' ��UNOABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> A�Wy <br /> _ APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY fpgdp gMIT TO IDN6TR ECT IS ANDF/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENTTITLE,CHAPT lf� B,3,BplD/IAE TAN*Al�1�F SAN JOAQUIN COUNTY PIBLIC HEALTH VICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDIIESSMR APNE �3 -� 's1ER ,l <br /> CITY <br /> OWNER'S NAME r,l A PARCEL SIZE/APNI <br /> AC C ! <br /> e. p�� ADOflE6s ©\ <br /> CONTRACTORIYIli I. � A <br /> SUB CONTRACTOR <br /> �L.LLSGL—PHONE I���>1.�1J.yl <br /> ADDRESS <br /> LIC# PHONE# <br /> TYPE OF WELIJPUMP: ❑ NEW WELL ❑ HFPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR El VAPOR EXTRACTION WELL <br /> Tv v ❑Now Nq RepN, H.P. oeQQ DEPTH PUMP Ste/ <br /> mPE OF PUMP) 'y�FT FIRST WATER LEVEL`.�Q <br /> — ❑OUT-OFFSERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING O <br /> DESTRUCTION: <br /> S <br /> INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING A , <br /> ❑ DOMESTIC/PRIVATE 13 GRAVEL PACK/SIZE D ^ <br /> WIMV <br /> TYPE OFF GROUT <br /> REEUPVC DIA,OF WELL CASING <br /> ❑ BLILUNICIPAL DRIVEN <br /> DEPTH OF GROUTOUT SEAL C❑ SPECIFICATION <br /> IRRIGATION/AG OTHER GROUT SEAL INSTALLED 6Y % V <br /> ❑ MONITORING GROUT SEAL PIMPED: ❑V. ON. GROUT BRAND NAME E, C <br /> CONCRETE PEDESTAL BY DRILLFR:❑Ya [IN s <br /> APPROX.DEILOCKING CHESTER BO%/STOVE PPF <br /> RIOMSED CONSTRUCTIONIDFILLING METHOD: MUD ROTARYS v <br /> AIR ROTARY AUGER CABLE <br /> OTHER <br /> — 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(VALL BE DONE IN ACCOflOANCE WITH BAN JOAOUIN COUNTY 011DINANCES.STATE LAWS,AND RULES ANO r <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATUF CERTIFIES w <br /> THE FOLLOWING: "I CERTIFY THAT IN THE PEflf0 MANCE QF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMRDY PERSONS SUBJECT TO WOKIKMAN'6 COMPENKA N EAR'S OF / <br /> CAUFO AR CANT MUST CALL 1 R$IN VANCE FOR ALL REQUIRED INSPECTION$AT 120$1 N6J420, COMPLETE DRAWING AT LOWER AMA FRDVIDEO. <br /> 61va0% Tltle p��S Got <br /> PLOT MAN IOK b Seale)Style to TO <br /> 1. NAM SOF 6THEEPF OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED �1 <br /> — 2. OUTLINE OF THE OUTLINES <br /> Y.AN GIVING ION OF <br /> AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> D. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION OF WELLS WITHIN RADIUS ON <br /> HUNDRED FIFTY Ff. <br /> ON THE PIOPERTY OR ADJOINING PROPEPE RTY. <br /> n <br /> Zr <br /> 3S Frt <br /> T- <br /> SEP 1 13 1991- <br /> DEPARTMENT USE ONLY <br /> APPii Inco AFo,B BY v pate L Z— l Ara /--_•-- <br /> e,uu[I,.Patien BY ae Pun P ImPstlPn Br <br /> Dat,Netmn IrNPsfren Br Da. r <br /> cemmeme: <br /> ACCOUNTNO ONLY: AIOI FAC# <br /> PE CODFl FEEINFO AMOUNTRFMIT013 .HEC ASH RECOVEDBY DATE PFNMITLLEAVICE REGUFdT NUMBER INVOICE <br /> Cf�(OxkL 'f <br />