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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVN;fS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON.CA 95201388 <br /> (209)468.3420 <br /> ROU-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICampIEtE In Trlplieah) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH I <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OFSANJOAQUIN COUNTY <br /> TPUBLIC`PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSAIR APNI O M u r I'I/L'�_n`,S 1\ '..J CITY J 1 o c K 1�0� f� PARCEL SIZE/APN) <br /> OWNER'S NAME MR . M❑n1LtQ1 Sf,r'1L II 9-21-- <br /> ADDRESS pf 7-40%R PHONE <br /> CONTRACTORADDRESS �7HO/yNEIPnl <br /> �SVSCONTRACTO6 Pp ) 'Z( <br /> 1 <br /> TYPE OF WELL/PUMP: ❑NEW WELL ❑REPLACEMENT WELL W MONITORING WELL S MvuN •M• wS ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL S <br /> ❑New❑Rp.lr H.P. DEPTH PUMP SET FT. ppFIRST WATER LEVEL O, <br /> ITYPE OF PUMP) ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL/ W SOIL BORING I L3c/R 1A J 7 y <br /> V b S f <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION <br /> /T/ / DIA.OF CONDUCTOR CASING <br /> ❑DOMESTIC/PRIVATE GRAVEL PACK/SIZE TYPE OF CASING/STEEIyVCJ GQ�,t)f yO DIA.OF WELL CASINO Z I f <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL S L SPECIFICATION 1 <br /> ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY�)LIS I1 \%R)I COV A GROUT BRAND NAME kt m4) A I4,e—(P/vw„Is IV <br /> K MONITORING GROUT SEAL PUMPED:64Y- (IN. CONCRETE PEDESTAL BY DRILLER:WY- [IN. <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIOWDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER_\�CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES I <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTII <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWE <br /> CALIFORNIA.' TME CANT MUST C(/AI,L'24 110 N ADVANCE FOR ALL 11101"60 INSPEC NS AT 12 1 44 22.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Sgn.d X� ,dl/1/1 I��L Tltl. C,O7 G Is I D.t. I 7 <br /> 1 191 <br /> PILOT PUN(Dt.w to SuIO <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> - <br /> ... - .. .: .. ... i ... ... ' <br /> ► - <br /> pc.tIIl T`/`J DEPMTMENT USE ONLY �Z / v 1 <br /> Alilon Aecpl.d BY Mm r <br /> G'ow Imp.etlen BY O.t. P—P Irov.etIo By D.IS <br /> 0-t—tien Ir P.ctl/on By De. ' <br /> cemme,t.: �(��� �.L`.1'-E1MA (Gi✓CS�Q-t`��(?Q G� X � rOVLnBw��UI u�"( <br /> ACCOUNNNO ONLY: AIDS FACT <br /> PE CODES FEE INFO AMOUNT HOWTTED CHECKS/CMH RECEIVED BY DATE "ANUT/SL7WICE REQUEST NUMS91 INVOICE <br />