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APPLICATION FOR WELUPUMP PERMIT <br /> .,N JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST,STOCKTON,CA 96201.388 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (GmPMt&In Triipr&t&) <br /> APPLICATION 16 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO,OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE W COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOBADORES=RAPNI 1856 Field Avenue -CITY Stockton PARCEL STZVAPNf <br /> OWNER'S NAME <br /> James i4air ADDRESS 511 Div ,tCampbell�tt�NE.0,5008 <br /> CONTRACTOR Woodward-Clyde ADOFES6 0370 /• PHONEF 9163680988 <br /> SUBCONTRACTOR Spectrum Exploration ADDRESS amento, CA 95827 Ho <br /> ^ PHE7 2094658712 <br /> �J—66 <br /> TYPE OF WEIINUMP. ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL/ ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL S .� <br /> ❑N-❑Pep, H.P. DEPTH PUMP SET---f-r. FIRST WATER LEVEL 0 <br /> (TYPE OF PUMP) <br /> ❑OIJT-0FBEAVICE WELL ❑GEOPHYSICAL WELLS ❑ 601L BORING B <br /> LILESTRUCTION: EXi s ting Moni 1-nri ngL•'P1 T S <br /> INTENDED USE TYPE OF WELL CONSTAUCTiON fPECIFiCAT10Nf A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA OF CONDUCTOR CASINO D <br /> ❑DOMESTIC/PRIVATE ❑GRAVEL PAD:KraE TYPE Of CASING/STIndPVC DIA OF WELL CASING D <br /> ❑PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFKAT)O R <br /> ❑I1IPoGATIO WAG ❑OTHER GM'-SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONITORING GROUT SEAL PIMPED:Fly- ❑Ne CONCRETE PEDESTAL BY DRILLER❑Y.. ❑No S <br /> A'PROX.DEPTH - LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTION/DPoLLING METHOD:MUD ROTARY _ ,_AIR ROTARY AUGER i\ CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND fHATTHEW0PIK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,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 IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.*CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORXMAN'S COMPENSATION LAWS OF <br /> CAUFORMA'T WT C CE FOR ALL REQUIRED INSPECTION&AT(200)443-3427.COMPLETE DRAWING AT LOWER AREA PROVIDED. q <br /> 516n.dX �, 24 0 &IN ADVANT10e Geologist. <br /> i;lil Los ut __ <br /> ►CDT R/IN IDr..v l0 6W.1 Sole 'to <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.0UTUNE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANMN 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. 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AX.: .. ... .. <br /> .................... <br /> e AOENCOUNTY <br /> ......_ <br /> ......:...... _ ..... . w <br /> ' <br /> ....4....... .e......1».......... <br /> a <br /> '•.EM/IRONMENTAL HEAL TH IDV SIGN <br /> • K .. DEPART _-1 <br /> ORIr' <br /> APpfk.Uon Aoey[M Br .`y�� D.r.Dn-I At <br /> G,-SsP d_BY D.t. P-P WP.ctbn BT <br /> Carv­ <br /> ACCOUHTINO ONLY: A1DI FACT <br /> PE COD" FFEINFO AMOUNT REFATTTED HECK/ AIH RECElyp BY DATE ►DOLT/SERVICE REOUE&T NUNIRM INVOICE <br /> 0 770 <br /> Lq Vy <br />