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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NDN-REFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete M TI)plkets) ' <br /> APPLICATION 1911EPE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WPTit SAN <br /> JOAQUIN COUNTY DEVELOPMENT TIRE,CHAPTER 8-1115.3 AND THE STANOARDS OF <br /> � II \ BAN _ EEALTHSER�VICES.ENVIRONMENTAL HEALTH DIVISION.N_. <br /> JOB ADORE89 � � PARL SIZEAWI 7`17"/6�7�/00-bO RNAME�I ADDRESS :�P <br /> , <br /> Z <br /> COW TOR ADDDRR�E�TB,eLJ�'��_/tlCh/mac <br /> SUS CONTRACTOR ADORE36- `�-• J LICIPHONE I <br /> TYPE OF WELUPUMF. ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL I ❑OTHER <br /> ❑INWALLATON ❑WELL SYSTEM REPAIR Cl CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL• ,/ <br /> (TYPE OF PUMP) 11N-0 P W, N.P. DEPTH PUMP SET FT FIRST WATER LEVEL O <br /> ❑OUT-or BmvICE WELL ❑GEOPHYSICAL WELL! & SOIL 9011IN0 g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRLK:TION SPECIRCATIONS q <br /> ❑INDUSTRIAL ❑OPEN BOTTOM <br /> 11 DOMESTIC/PRIVATE 11 GRAVEL PACK/BRE DIA.Of WELL EXCAVATION 2 11 DIA.OF CONDUCTOR CASINO p <br /> TYPE OF CASINO/STEEL/'VC DIA.OF WELL CASINO p <br /> ❑PUBMIMUNICIPAL DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> 11IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY��r/ 011OW BRAND NAMEEfoct <br /> E <br /> ❑MONITORING �^ GROUT SEAL PUMPED:❑Vr ❑N. CONCRETE PEDESTAL BY ORLLER:❑Vr [IN. 5 <br /> APPROX.017TH ,J LOCKING CHESTER BOX/STOVE PPE 5 <br /> PROPOSED CONSTRUCTION/DRLLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER�fb <br /> I HE%SY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOFK WALL ME DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT N THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT 19 ISSUED,1 814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUB-COHPMCTNG SIGNATURE CERTIFIER <br /> THE FOLLOWING: 'I CERTIFY THAT N TIRE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 Te SUEO.1 SHALL EMPLOY PERSONS SUBJECT TO WORIGSAN'S COM► IIATTON LAWS OF <br /> CALIFORNIA.- THECANT MUST C U11R IN ADVANCE FOR ALL REOk"M INSPECTIONS AT 12001 4*0 /29.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 1 <br /> /�nqYn �- <br /> SlSrrd X 1L.� ') TIG. \.Y// D.1. L <br /> ROT PLAN fl>—le 94"9..4 'I. <br /> R <br /> 1.NAMES OF STREETS OR RADE NEAREST TO OR BOUNDING THE PROPERTY. S.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUIM <br /> OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DI9POSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINER AND LOCATION OF ALL EXIS11N0 AND PROPOSED 0.LOCATION OF WELLS WITHIN MDIUR OF ONE HUNDRED FIFTY A. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAUKe. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> :. ...... <br /> ,. l <br /> 1 <br /> . ... .:........ .......:.............:..... ..... ...........;.......:....................... <br /> DErAATMENT USE ONLY <br /> APPSe.Rarl Aae.PN.a ST <br /> 01—I, 11..of <br /> D-111.1 w.ImP«Ibn Br OH• <br /> Ca„ms.l.: o en c s-DG[f.c._a�/J �. .i [L �J — O aN�c -S/4.k-v ?F..1�,r r a/r i�✓ <br /> Gtr � <br /> ACCOUNTING ONLY: AlD/ FACT <br /> PE COVES FEE INFO AMOUNT REMITTED CHECKS/CAB" RECEIVED■Y DATE PB0r11T/SERVICE REQUEST NUMSEII INVOICE <br /> �1)/ o" ?P0 <br /> 1�3� aha/ts zs-- <br /> Pub Health Sem.-EnvirO.173(1/97) <br />