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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> N, ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, "S N.SAN JOAQUIN ST,STOCKTON,CA 86201188 <br /> (209)468-3420 <br /> RON•REFUNDABLE PERMIT EXPIRES 1 YEAH FROM DATE ISSUED <br /> (Complete in TFiPIk818l <br /> APPLICATION 1!'HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS M4LICATION IS MADE M COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENNTS TITTLE-CHAPTER <br /> /9 11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, <br /> EE'NN'VW93N'QML,ENTAL HEALTH DIVISK'M. <br /> JOB ADORESSlOR AIN( ( I--- J_0�l / CITY 1 ^/t /,I7v4/1 <br /> //1�1}/1�7{/_�J- <br /> OWNER'S NAME,�//�1 J1 �'J AOOOESS V YET {`� 'j 1� �l 4 ■( ` 0n 7 I, /}PHONE.0 <br /> CONTRACTOR I_V I I ` / AOORESS 2-`-Z` C C �' `t� LIC/ <br /> SUB CONTRACTOR ADDRESS LACI _PHONE• <br /> TYPE OF WEUU UMP: [3 VFW WTLL EMENT WELL 11 MONITORING WELL E 13 OTHER <br /> BG INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL P J <br /> 0-k--❑Rw' H.P._ z DEPTH RUMP SET FT. FNUST WATER LEVEL O <br /> (TYPE OF PUMPS ' <br /> ❑ -0VIC <br /> RIT1// OUT -SERE WELL ❑GEOPHYSICAL WELL/ 1:3 SOIL BORING B <br /> L7DESTRDC TION: <br /> INTENDED VSE TYPE OF WELL CONSTRUCTION{PfLIiC ATIO NI I A <br /> 1F-3�INDUSTRIAL ❑❑^OPPE'EN BOTTOM DIA.OF WELL EXCAVATION L DIA.OF CONDUCTOR CASINO aa� C O <br /> E.VDOMESTICNWLJY <br /> VATE GA#.VEL PACX7SQE_2l TYPE OF CARINGSTEEUPVC DIA.OF WELL CASING 61/ D <br /> ❑ PUBUCIMUHICIPAL ❑DRIVEN DEPTH OF GROUT SEAL Itt 1 SPECIHCATIDN '40 by/ R <br /> 11IMMIGATIOMAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME 220'(I--� E <br /> C1MOMTONNO 7 r GROUT SEAL PUMPED: Vw ❑Ne CONCRETE PEDESTAL BY ONLLER G<-_/ ❑No S <br /> APMO)I.DWTH Z 1 LOCKING CHESTER BOXISTOVE RPE_ 5 <br /> RROPDUM CONSTRUCTIONIOIeWMG METHOD: MUD ROTARY/ AIR ROTARY AUGERi__CABLE OTHER <br /> 1 HE9EBY CERTIFY THAT 1 HAVE REPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE OATH SAN JOAGUIN COUNTY ORDINANCES,STATE LAWS.AND RULES ANO-� <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLUDWIHGi:'I CERTIFY THAT IN THE PMORMANCE OF THE WORK FOR WHICH IZN <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HRNG OR SUB-CONTRACTING SIGNATURE CERTIRES o , <br /> THE FOLLOWING:tEffI TI T T RMANCWORKF:lq WHICH THIS PERMIT IS ISSUED,16HALL EMRAY PERBON6 SUBJECT TO WOIIpAAM'{COMPN{ATIOM LAWS OFNCALJFOFW IA,' TA W 1 AMC!FOR ALL AEGUe1�INSPIG AT(20{1 MJIe3U28.COMPLETE DRAWING AT LOWER AREA F'HDV/XIO-ED[!��/J <br /> Sign d X y� D.. <br /> RAT PLAN ILII—I.ScaN.l Sod. -I. Iy <br /> 1 NAMES OF STREETS OR ROADS NEAFEST TO OR BOUNDIING THE PROPERY.TC LOCATION OF HOUSE SEWAGE DIBPORAL SYSTEM OR fMOPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION_ EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 4 <br /> J. DIMENSIONED OUTUNES AHO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE MNDRm FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED MEAS SUCH AS PATIOS,DRIVEWAYS,AND WALXS ON THE PROPERTY OR ADJOINING PROPERTY. <br /> . . . . . . . <br /> ..... <br /> . . . . .... .., <br /> ............................... . <br /> 4firt <br /> i <br /> , .. . . ... .. .... ..... ... r ............... ...... ......_ <br /> ' a <br /> -. ��a.. :.....: . .'. <br /> ;. ; <br /> IIAEI� <br /> _ . <br /> RECEIVED <br /> �c <br /> :. .: <br /> .......... S©NJOAQUIN 4Rv�-t5PIAALIRDIV151 <br /> . .. . . . . . LNV1Rf)NMET0._ . <br /> DEPARTMENT USE ONLY <br /> A0p4b.t1.n A.IIpt.E BY .Z IIw - <br /> Grout Inw.olbn BY �t Dna f O PwnP Wp.nbn ev « _DOO <br /> Dwvu.uonIrM><tion.1 •L� lL1.t-E-rT- 7 y 1 Dn. g I <br /> comm.ms:� �A{ !aJ[ �e <br /> ACCOUN.ONO ONLY: /UDM FAC# <br /> PE/.ODFH FEE INFO AMOUNT REMITTED Et N;ASH IIECFN ED BY D E P9MRTM RVICE REQUEST M ER INVOICE CJ <br /> L�3L AS <br /> O Don <br />