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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 55201388 <br /> 12091469-3420 <br /> NON-REFUNDABLE PE <br /> NR�MI <br /> ITIsto M <br /> T EXPIRES 1 YEAR FROM DATE ISSUED <br /> AP(CATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FpR A PERMIT TO CONSTRUCT, AL <br /> NDbnINS-TALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WITH SAN <br /> JOAOLIM COUNTY DFVEIOPM FNT TITLE.CHAPTER 9 111 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY/PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADDRESS,"APNf 0700 � w Z CITY LGA <br /> OWNER'S NAMF�L< L f'� PARCEL SIZE/APHI Z4;.4,— S <br /> y/1 1� ADDRESS /l/ yi;- 't 6/—v /I 21-1/. PHONE E <br /> CONTRACTOR_ //!3 1 /C GT ADDRESS y/4. LICE 2779'/7 q <br /> / PIgHE/ 3L�3/J9 <br /> 6De CONTRACTOR -,////{� ADDRESS <br /> UC. PHONE f <br /> TYPE OF WEI(PUMP, ❑NEW WELL ❑REPLACEMENT WELL �❑MONITORING WELL f OTHER /L/f <br /> 11 INSTALLATION 13WELL SYSTEM REPAIR y(J C----CONNECT REPAIR ❑VAPOR EXTRACTION WELL/ <br /> 'g\ ✓ <br /> NK„❑Rr.6 H.P. <br /> (TYPE Of tiMPI DEPTH PUMP SET R. FIST WATER LEVEL <br /> O <br /> ❑OUT-OF•SEAVICE WELL ❑GEOPHYSICAL WELL. ❑ SOIL SOP HO S <br /> 11 DESTRUCTION: <br /> INTENDED VFt Typs CONSTRUCTION SPECIR T10.6 <br /> E3 <br /> -L <br /> ININDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO AQ <br /> G <br /> D <br /> OOMESTICRNYVATE ❑GRAVEL PACK/SI7f TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING DTTT <br /> ❑PUBLICMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> 11 R <br /> IRRIGATION/AO El OTHER GROUT SEAL INSTALLED BY OFIOIR BRAND NAME x <br /> 11 f <br /> MONfTORING ORO VT SEAL FV MPFO:❑Yr ❑Ib CONCRETE PEDESTAL BY DRILLER❑V. ON. <br /> APPROX.DEPTH LOCKMO CHESTER BOXMTOVE RPE <br /> s ry <br /> PROPOSED CONET/RJCTONAXAlLl1N0 METHOD; MVD ROTARY ABI ROTARY AUGER CABLE OTHER 1 <br /> HEREBY CERTIFY THAT I NAVE PLEPARED THIS ATPLICATION AND iNAT THE WOTK PALL SE DONE M ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGIIUTY>NS OF THE SAN JOAQUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOLMNO''t CERTIFY THAT M THE PERFOMIANCE OF THE WOW FOR WHICH <br /> THIS PERMIT re ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP04SATION LAWS OF CALIFORNIA.' CONTRACTOR'S HrfYNG OP SUBCONTRACTING SIGNATURE CERTS'IF6 <br /> THE FOLLOWRNO; 'I CERTIFY THAT IN THE PERFORMANCE Of THE WOES(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO INVIR PAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE AL MUST yALL H MOURS M ADVANCE ROP ALL REDULIED INSPSETIONS AT 12-1-- -. COMPLETE ORA—AT LOWER AREA p11pNDFD. <br /> . I /u y�_QL.._ � / <br /> 1 <br /> I0 <br /> 1.1 <br /> X— <br /> TIIIe �4�+A+�i�-T //-!S Z ✓ ��G�"' <br /> 3 Co. Z <br /> PLOT PUN tD—I.9".I 6w1. <br /> EET <br /> 1. NAMES OF STAS OR ROADS NEAREST 70 OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR pnorogED <br /> I.OUTLINE Of THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 7.DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTG AND PROPOSED S. LOCATION Of WELLS WN RADIUS OF ONE HUNDREO FIFTY FT. <br /> STRUCTURES,IMRHI <br /> NCLUDMO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PPDPERTY. <br /> _ N _ <br /> clc.oc.I"'IF�... . . . . <br /> 4u.11 <br /> p°'`3 <br /> w>'AYh9EN t <br /> FEBT. <br /> 1 51996 <br /> . ........ N JU <br /> P <br /> -NV1q0rt1MHEAL k$EP <br /> D V ROY <br /> E'NT Lk1EgtTy r <br /> OEPMTMENT USE ONLY <br /> ApPlk.tlen Axrl.e BYS IOM. V � � '- <br /> a.e,A Imp.Fllm Byy Dom. A,mP 1�.o.�uo�eY o.t. <br /> Ibn tiPrtlen BT <br /> / b.t <br /> ....-TING WILY: AID/ I.C. <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE ►llE.1 T...PEOUEBT NlJ•.11ER INVOME ' <br /> o1 <br />