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' APPLICATION FOR WELLIPUMP PEP-"'T <br /> JOAQUIN COUNTY PUBLIC HEALTH VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED <br /> (Com <br /> Sets <br /> JOAQUIN <br /> APPLICATION N Y DE EL MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT t0 ONSpRUCTIAND/OnINSTALL THE WORK DESCRIBED:TlIIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH BERMES,ENVIRONMENTAL HEALTH DIVISION. - <br /> JOB ADDRESS/OR APN/ /,S ..•. CITY <br /> ••--- PARCEL SIZEIAPN/ <br /> OWNER'S NAME <br /> �C <br /> }' �p ADDRESS 0;Ct PILON <br /> CONTRACTOR_ 'Y1. 'K e+YdA'rE. <br /> ADORE 88 « 5��$—LIC/ PHONE 022� ,�/,�` <br /> RUB CONTRACTOpP C GC �! - �'�ADORE 8 s �C LICX PHONE Ny <br /> TYPE OF WELUPUMP: © NEW WELL ❑ REPLACEMENT WELL hTONRO ING WELL A A,J d- ❑ OTHER , <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR Cl VAPOR EXTRACTION WELL f <br /> ❑New LI Rapelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> RYPE OF PUMPI 0 i <br /> ❑ OUT-OF-SERVICE WELL N ❑ GEOPHYSICAL WELL# © BOIL BOMNO B <br /> ❑OESTRUC71ON: j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> A 1 <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p I <br /> ❑ <br /> DOMES TICIPRIVATE ❑GRAVEL PACX/SIZE TYPE OF CASINGISTEELIPVC DIA,OF WELL CASINO U } <br /> ❑ PURUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 5t SPECIFICATION <br /> ❑ IRRIGATKONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> A MONITORING <br /> GROUT SEAL PUMPED: ❑Y. H No CONCRETE PEDESTAL BY DRILLER:❑y— Na 5 <br /> APPROX.DEPTH - LOCKING CHESTER BOXJBTOVE PIPE 5 <br /> PROPOSED CONBTRUCTIONAMLLING METHOD- MUD ROTARY AIR ROTARY AUGER k- <br /> --_..CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,ANO RULES ANDIN <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'•COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR OU"-CONTRACTING SIONATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURED IN2PECTtON$AT 12021 462-2427. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slpned X <br /> _ befe <br /> / <br /> PLOT PIAN{Draw to Soelel See1e� JW <br /> _•to r <br /> 1. NAMES OF STREET$OR ROADS NEAREST TO OR SOUNDMO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 4 <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENS1ONEO OUTLINE$AND LOCATION OF ALL EXItTT1NG AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS OUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> Fi <br /> M <br /> _ pr,GSr <br /> at <br /> ... .�sa..... <br /> ,, r <br /> I <br /> � 1 + , <br /> .. .. .:....... . ...... <br /> EN V$E OMLr <br /> Apppcatlan Accepted BYZ-- i beta Ares <br /> fi <br />