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APPLICATION FOR WELIJPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> ROM-REFUNDABLE PERMIT EXPIRESI 1 YEAR FROM 0AiE ISSUED <br /> {Compht� In T�IpBettdl <br /> APPLICATION 18 HERE BY MASE TO THE CAN JOAQUlN COUNTY FOR A PERMIT TO CONSTRUCT ANDIon INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE4/ 1,;:, <br /> CHAPTER 8-1115.3 AND THE BTANDARD8 OF SAN JOADUIN COU PUBLIC HEALTH SERVICES.ENVIIFIONMENTAL HEALTH DIVISION, <br /> JOB ADDRESS/pR APCITY ! ! PARCEL BIZEIAPNff OWRIEA'8 NAME lA ^, I �' � P110NE• (,J#CONTRACTOR IF I ]'�'J] <br /> ADOREBa UC j PHONE# SZg �7J f <br /> PUB CONTRACTOR ADORE ITB <br /> UCP PHONES <br /> TYPE OF_ WELLIP!JMp.- ❑ NFW WELL ❑ AEPIACEMENf WEIL ❑ MONITORING WELL S ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM F11 IR ❑ CROS"ONNFCT REPAIR ❑ VAPOR EXTRACTION <br /> W/F�LL/1'jr�''�� J <br /> 0 YPE OF PUMPI ❑New❑RoI H.P. DEPTH PUMP S i FT. FIRST WATER LEVEL !(f/ <br /> O <br /> �( /! ❑ OUT-OF-BEgVICE{+ LL ❑ OEDPHYSICA1 WELL/ ,P ❑A SOIL BORING B <br /> J�DESTRUCTION: CCC/t <br /> IN7ENAEp VtE TYPE OF WELL I `�. .p <br /> CONSTRUCTION SPIECIFICATION! 11.. <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I A <br /> ❑ OOMESTICIPNIVATE ❑GRAVEL PACXIB12E TYRE OF CASING/BT FEL/PVC I DIA.OF CONDUCTOR CASING D <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN SPEC I F WELL CASING D <br /> OEM"OF GROUT SEAL I SPECIFICATION <br /> ❑ IRnmAT10N/AO ❑OTHER B <br /> aROIfT SEA[INSTALLED BY I GROUT BRAND NAME <br /> ❑ <br /> MONITORING E <br /> GROUT SFAL PUMPED! ❑Yrc [3m. CONCIIETE PEISE8TAL BY pRlLLER;❑Ye. ❑Ne g <br /> APPROX.X.DEP'7H ,... LOCKING CHESTER BQXJSTOVE PIPE <br /> PROPOSED CONETRUCTroNMRILLINO METHOD; MUD ROTARY AIR ROTARY I AUGER S <br /> CABLE OTHER <br /> I"MBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN I ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> ItEOULATIONB OF THE SAN JOAQUIII COUNTY, HOME OWNER OR LICENSED AGENT'S SIONATUM CFR IFIEB THE FOLLOVAW!'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICII <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTlVICTp I HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIER <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOWS FOR WHICH THIS PERMIT 18 TISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEIIPATION LAWS OF <br /> CAUFDRI THE CA MUST CA HOURS IN ADVANCE FOR ALL REQUIRED IN 714NS AT fxOSl�Ib?t;X• COMPLETE DRAWING A7 LOWER AREA MIOVIbEO. <br /> 81or+ed X Ty4, Title ' <br /> Dote <br /> PLOT PLAN Mraw to Saalel Sea 'to <br /> I. NAMES OF 8 REETB OR ROAD$NEAREST TO OR BOUNDINO THE PROPERTY• <br /> 2. OUTLINE OF THE PROPERTY,01I I MENMONS AND NORTH DIRECTION. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROP08ED <br /> 7. DIMENSIONED OUTLMIF.B AND LOCATION OF ALP.EXISTING AND PROPOSED EXPANSION F SEWAGE DISPOSALNRADIUS <br /> S OFO SYSTEMS. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AHD WALKS. 8• LOCATION OF WELLS WITMH MDIVS OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOIN7M PROPERTY. <br /> n; <br /> � 1 <br /> a <br /> 04 <br /> DEPARTMENT <br /> DEPARTMENT VSE ONLY 0 Z l�'7_ <br /> AeplleaHen Aeeepted BY_. �}'��Pp <br /> A.we <br /> Grein Fr+.pmtlon BY Date Pump lneprellrn BYI <br /> Dea,nJctlen I�Ps�Nen BY - � Q/f k I Dole <br /> lnl��lf �i D.,. <br /> Jam/ J` -5-gw6l� hT ,LtiyGs! �'`+rC.4 ���✓C 73'�is.,�«-LA 6 <br /> ACCOUNTING ONLY; AIDP <br /> PE CODE! FEE INFO AMOUNT REMITTED !CASH RECEIVED BY DAI TE PERMITAERVICE REQUEST NUMBER INVOICE <br /> i <br /> sz� l d 1t I c lg 3 <br />