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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 /> PION-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Compists is Tripikatol <br /> APPLICATION IB IIEK BY MAGE TO THE SAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.TIUS APPLICATION 16 MAOE IN COMPLIANCE WITII SAN <br /> :OAOUIN COUNTY DEVELOPMENT TRLE.CHAPTER 9-1115.3 AND THE STANOARDS OF SAN JOAOUN COUNTY PUBLIC HEALTH SERVICES.ENVNIONIUENTAL HEALTH 09VIMN. <br /> ^ ,p � ^ EIAPNR <br /> SGB AooREBB/oR APr+P � I• <!C -t�' /�It:•'1 11 f= _ crry PARCEL SIZ <br /> (_ - � 'frr'�1 <br /> OWNER'S NAAIE��1r i I v1 L(li Tj i /� 'I X' +•1,i AooREss r CL'x !. ��{r PHONE r <br /> COMPACTOR��1!'t�I N �•Ill 1 C'.l^ 1r�.'1/I% i 1��;! •r f t 1 AOOIEso�)Cl•�«n::se''^f�t PHONE T <br /> i1�- /1 .11L' <br /> + Y r ADDRESS �� i1' LICI�r=. -I C zT f/_ <br /> sus CONTRACTOR <br /> < T <br /> TYF!OF WELUPUMP: 13 New WELL E3 REPLACEMENT WELL ❑ MONRONNO WELLI C3 0,HE <br /> ❑ INBTAALlATWN ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAMP EXTRACTION WELL J J <br /> ❑N.M.❑Rtt sl. M.P. OEPTH PIMP SET FT. e�FIRST WATER LEVEL <br /> RYPE OF PUMP Lyi5 `✓� 8 <br /> ❑ OW-OF-SERVICE WELL ❑ GEOPHYSICAL WELL• Boll sOlerq(]V <br /> ❑DEBTRt/CTION: <br /> INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM OIA.OF WELL EXCAVATION �.__�_ DIA.of CONDUCTOR CASING O <br /> TGAN <br /> DOMESTIC/PVATE ❑GRAVEL PACXMU TYPE of CAMINGISTE'ELIP/C DIA.OF WELL CASOM 0 <br /> 0 PUBLICOAUNICIPAL ❑ONVEN OEPTH OF GROUT sm SPECIFICATION R <br /> 0 0tl11GAT10N/AG ❑OTHER GROUT SEAL MBTAU,ED BY GROW BRAND NAME E <br /> 0 MONITORING GROUT SEAL WMPED:Cl Y. ❑N. CONCRIM PEDESTAL BY DRILLER:Cl Y— ❑H. s <br /> APPROX.DIEFT14 Loc MO CHESTER SOXXTOVE PIPE s <br /> PnOPOam CONSTRUCTRON/DMUDn AASTHOO: MUD ROTARY MR ROTARY AUGER CAKE OTHER- <br /> 1 HE*EsY CERTIFY THAT I HAVE PREPARED TWS APPJCATMH ANO THAT THE WORK WILL BE DONE M ACCORDANCE VVRN SAN JOAOUN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REOULATIONB OF THE SAN JOAQUN COUNTY. HOME OWNER OR L ICOMED AGENT'S SMNATUIIE i THE FOLLOWING:7 Can, TNAT N THE PERfO11MANCE OF THE WORK FOR TIF ES <br /> T W S PERIMRT M Is1l1ED.1 SHALL NOT EMPLOY PERSONS ItMJECT TO WOM MAW$COMM"TWN LAWS OF CALNW"A.' CONTRACTOR'S Mon OR SL41- NTRACTNG fNGNATUIE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT N T11E� FIFORIJ AMCE OF THE WORK FOR W"M TM P8%%GT IS ISSUED.I SMALL EMPLOY PERSONS wMJECT TO WOISaRAN'a COMP9RSA110N LAWS OF <br /> CALIFOR NI APPLICANT <br /> MUST CALL NOW IN ADVANCE FOR ALL REMPRIND TIONS AT 1201)440-3122. COWCETE ORAVWM AT LOWER AREA PROVIDED. <br /> Two <br /> PLOT PLAN Drew to So"P 'to— <br /> SAI.SYSTEM OR FROM" <br /> I. NAMES OF STREETS OR ROADS NEAREffr TO OR M MONO THE PROPERTY. 4. LOCATION OF HOUR/SWAGE <br /> t. OUTUNE OF THE PROPERTY.Orion ONtBp10Ns ANO NOIR"011ECT10N. Ex/ANMON OF aEWAOE OISPOSAL SSYYSTEMS. <br /> pRI1FNBlOr®OtfftleiS AND LOCATION OF Yl.VAWFWM ANO P011000 O.. ..a..encATtMe OP VI/I I1 vlarw NNARIisNra nomw NeNNNrtesn ae'v e <br /> _............: ..: ..._..... _ ... .. ... . ............ ... ... .. <br /> .. .. <br /> .. . . - <br /> .om.: <br /> I <br /> OEPARTMFlRT USE fNQY <br /> S' <br /> DnP <br /> APPSPNWn Aeser"d By <br /> o.e..t 1,....tb..Byw 110 - ON <br /> Dom ` - <br /> R^�en.¢tlen Ienptetlen r ...� --4V <br /> C•.ww..s.t�• <br /> ACCOUNTTNO ONLY: NO! FAC/ <br /> K CODES FEE INFO AMOUNT RIMTTED CHECKSICASH sY DATE F911ST/1t31NCtf REOVSST NIlJ1SS@1 <br /> INVOICs <br /> 3501 !Z 2� <br /> 1 <br />