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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 /> 468-3420 <br /> I {los) � <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> [Complus In TFpneito <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORT(DESCRIBED.71118 APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELGPMENT TITLE.CHAPTER 9-1115-3 AND TARE STANDARDS OF BAN JOAQUIN COUNTY PUBLItC,,IEALTIt SERVICER,ENVIRONMENTAL HEALTH DR AWN. <br /> C <br /> JOB ADORE881OR APNI •`G"�`ikkV `6' ��5 - 1J`� {ty'f CITY 'I`1� PARCEL SIZEfAPN/ADDRESS -1 C� O � S} . F.W/ 71�;? �;5 <br /> OWNER'S NAME <br /> CONTACTOR <br /> Y j<•::L.iCi•T'L Lv`� - AGGRESS IIIA Lz--14L- Petkw, ucr rHONEI <br /> PR <br /> SUBCONTRACTOR VvQ..S� •� ADDREBB • F'•1 t+--+Ad uc;F 'irk MOW i4`y.'•�Z3•�' <br /> TYPE'OF WELUPUMP; ❑ NEW WELL ❑ FIEFLACEMEHT WELL ❑ MONITORINO WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO98-CONNECT REPAIR CI VAPOR EXTRACTION WELL I <br /> I ❑New❑R-p.k ".P. DEPTII PUMP BET FT, FIRST WATER LEVEL O i <br /> [TYPE OF PUMP) <br /> ❑ OUT-0F-SERVICE`VaLL p t❑ OEOPLIYSICAL tWELL J li�--Orl-BORING `3 ) 8 <br /> ❑DtSTRtMTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i A <br /> ❑ IFIDl16TRlAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Y'i VIA.OF CONDUCTOR CASINO y P <br /> ElDOMESTIC/MVATE ❑ORAVEL PACKlB17F TYPE OF CASINOISTEELMVC VC DIA.OF WELL CASINO 11 D <br /> C3PUBUC/UU14tCtPAL fC❑LMi1VEN DEPTH OF GROUT BEAL f SPECIFICATION S fL�-` 4 A' qc A <br /> �❑ IIRRIOATIONIAO ed OTHER GROUT SEAL INFrALLED BY ^}"U��'V"1'� a1 iA�'- OROUT BRAND NAME Y-yYl Ikoa''A- <br /> Jaa MONITOIVNO GROUT SEAL PUMPED: 1IK. [IN.Ne CONCRETE PEDESTAL BY 0R1LLER:❑Yr. S <br /> APPROX.DF9TH �� LOCKItNO CHEBTER 8OXMTOVE PIPE 5 <br /> PROPO2M CONSTRUCTTONIONLUNG METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br /> I HE9E8Y CEIMFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WELL BE DONE IN ACCORDANCE WITH BAN JOA13UIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> I REGULATIONS OF THE SAN JOAOUM COUNTY. NOME OWNER OR LICENSED AOENT'8 SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TtIE WORK FOR WHICH <br /> THIS PERMS IS IRSUEO,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION tAWS Of CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTTNG SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT tN T1tE PERFORMANCE OF THE WORK TOR WHICH THIS PERMIT IB IBBVEO.1 BNALL EMPLOY PERSONS SUBJECT TO WORILMAN'B COMPS NIATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUBT CA�t 24 HOUR*IN ADVANCE FOR ALL REQUIRED I146FEC110119 AT 12001 4SBA422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Da. rr <br /> PLOT PLAN(-aw is Serhl Berlr 'to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOM THE PROPERTY. 4. LOCAMN'OF HOUSE SEWAGE DISPOSAL SYSTEM OR pnOPOBfD <br /> 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF BEWAOE DISPOSAL BYRUM$. <br /> 2. DIMENMNED OUTUNF.B AND LOCATION OF ALL EXIBTIO AND PROPOSED S. LOCATION OF WELLe INTTHII RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURE@,81C1 <br /> o � IN <br /> 7 <br /> o w � <br /> g tu $ <br /> t <br /> = N <br /> w Q o <br /> OI �w <br /> 3NY1 N21Yd MON <br /> Y Q <br /> I N O <br /> I�J J iiH� <br /> M <br /> V_. <br /> �j <br /> {l(r� <br /> OF►MTME/It VeR ONLY <br /> V <br /> napnar,ton Aereepled By `G t� Area <br /> Dole % <br /> O.eu1 lr pewelen BY Dole RYmp Inraeeelen By <br /> Date <br /> I 0—elt-ft.I—pselon SY_�"�'r�'. 1 d" 3 S ep Y <br /> Vole <br /> C-40: <br /> r <br /> v <br /> ACCOUNTING ONLY: NOI FACT <br /> PE CODES FEE INFO AMOUNT REMITTED HE K ABH RECEIVED BY DATE r PEVMRTIJ104VICE REOUEST NUMBER INVOICE <br /> L 1 <br /> O„4. Llnnith C- 1 Fn%rirn 179!1-ln71 <br /> I, <br />