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APPLICATION FOR WELLIPUMP 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 /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER <br /> ICamplets In TEIpREtt■l <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANCHOR INSTALL THE WOW DESCRIBED.THRI APPLICATION IB MADE M COMPLIANCE WON SAN <br /> JOAQUIN COUNTY DEVELOPMENT <br /> T/TITLE.CHAPTER 8-11(115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH BERVICEe,ENVIMNMENTAL HEALTH DMIMN. <br /> JOB ADORES&OA A., {�,,��EM/ ��0[JI,�l ^V LQ ��3 CITY G'a�I D Lk 94(5;z <br /> y r r�PARCEL BIZEJAFNI�'Fr � OkC <br /> OWNER'S NAME IM E.'LO UG • S ADDRESS�h +/ S /H'l��l+� 7YO RA..A��PHIO E N <br /> CONTRACTOR CJ�I'y vQ Zt- �RJ ', ACKNI +7AC-1 cU�� 4�`C(') ucr�V23 PHDNE <br /> SUB CONTRACTOR AD 08 LIC# PHONE r <br /> TYPE OF WQAJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CSOSB ONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> 0H.11 ReeW N.P. DEPTH PUMP BET_FT. III WATER LEVEL O <br /> D VPE OF PUMPI <br /> ❑ OVf-0E-BERVIOE WELL ❑ OEOR1Y61CAl WELL A BOR BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL 13 OPEN BOTTOM DIA.OF WELL EXCAVATION dA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTIC ' VATE ❑GRAVEL PACK/SIZE TYPE OF CASINGRTEEVPVC DIA.OF WELL CASINO D <br /> ❑ PUBLICIMUNgRPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRISGATION/AO ❑OTHER GROUT REAL INSTALLED BY GROW BRAND NAME E <br /> ❑ MONITORING I GROUT BEAL PUMPED: ❑Y. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y. ❑Ne 5 <br /> APPROX.DEPTH IO LOCKING CHESTER BO%HITOVE PPE5 <br /> RROI HIED CONSTRUCTIONNll1 <br /> NNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERtO T�/���O AV G c_?. <br /> I HERBY CERTIFY THAT I IIAW PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE M ACCORDANCE WON BAN JOAOUIN COUNTY OMNANCES,STATE LAWS,AND RULES AND <br /> OEGLRATIONH OF THE SAN JOAQUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTEIES THE FOLLOWING:'I CERTIFY THAT M THE PETEOAMANCE OF THE WOISL FOR WHICH <br /> THIS"MIT IB IB (SHALL NOT EMPLOY FERBONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-0ONiRACTIM SIGNATURE CERfRES <br /> THE FOLLOWING- 1 C IFY THAT M Tl1E.P91FORMA pt FOR WNgN THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WO111WAN'S COMIdMHOn LAWS OF <br /> CALIFORNIA.' LIE A ANT MUST C <br /> FOR <br /> ALL RF011NRFD InEF[CT{M-INNS AT If0■1 ApJSff. COMePL�E/TE�D/RAVWNO AT LOWER ATEA PIgN QED./] <br /> BIy..M X L—�, / TNN E�G JU�3 Ct+G �ltO T- D.t. <br /> ROT TUN m.R.IB BeNFI <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BAM WNW THE RECTION. S. LOCATION OF HOUSE ESMAGE <br /> ONIPO DISPOSAL SYSTEM OR PROPOSED <br /> Z. OUTLINE OF THE AgPERTY,GIVNp DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE dRP08AL SYSTEMS. <br /> ]. DIMENSIONED ODTLMFR AND LOCATION OF ALL EXISTREG AND PROMI S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT <br /> STR TUBER,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR""DOW PROPERTY. <br /> .-4` + i <br /> I <br /> W N <br /> 3 <br /> / EPMTMENT USE ONLY <br /> APPiell" -V lM. 1 • MM <br /> roeul ImPkllen By D.Is RmP Imvmnen 6y blv <br /> Ornv¢Ben Imeenlen By Del. <br /> CommsNe' <br /> ACCOUNTING ONLY: AIM FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CNECKIHOASH RECFIV ■ DATE PERNSTISERVICE REQUEST NUMBER INVOICE <br /> cfo 0 z 0 -2-5-01-3 <br /> Ezctq s . zAlqq 0 Zoor <br /> Pub Health Serv.-Enviro.173(1/97) <br />