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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)458-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 TEAR FROM DATE 1S7UED <br /> (C"IstE IN TryhatF) <br /> APPLICATIDN le HEFIE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DECCRHED.TIPS APPLICATION IF MADE IN COMPLIANCE WRIT SAN <br /> JOAOVIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 D TII STAND0 SAN JOAOVIN <br /> CO MHTHmESENVIRONMENTAL HEALTH DIVISION. <br /> AODIEeS0R AJNI02 CRY PARCEL 812EJAPNPAZ� <br /> OWNR'S NAME ^tPG ✓`SIT <br /> I¢co9ne <br /> S <br /> ADDRESS "I RIONE �ly(�. <br /> CONTMCT011 LS r IK ADDRESS ucm1 ap LZ- PHONEIS2��7 <br /> SUS CONTRACTOM ADDRESS LICE PHONE E <br /> TYPE OF WELIRVMF, NEw WILL ❑REPLACEMENT WELL ❑MONY DISNO WELL 0 ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROIH CONNECT REPAIR ❑VAPOR EXTRACTION WELL I J <br /> V <br /> ❑Mo.11RAINY H.P. DEPTH PUMP SET__FT. FIRST WATER LEVEL O <br /> (TYPE of PUMP) <br /> ❑OVTdF-SERVICE WELL ❑OFOP StcAL WELL 0 ❑ BOR.BORING e <br /> ❑DESTRUCTION: <br /> INTENOLo USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A c <br /> ❑INOVSTRIAL 11 OPEN BOTTOM IDA.Of WELL EXCAVATION dA.OF CONDUCTOR CASINO p <br /> T <br /> �.AOMEBTICA'RIVATE WrAVEL PACK/BOE TYPE OF CASINO/ST EEL/PVC plye dA.OF WELL CASINO -.- <br /> ❑PUSL1CARNMCNILL ❑DRIVEN DEPTH OF GROUT WAIL lvdq SPECFICATION R <br /> xIRIVII ATION/A0 ❑OTHER GRIOVT SEAL INSTALLED BY 11111SI GROUT BRAND NAME F <br /> ❑Mom-roFSNO ^ ^ Gro VT SEAL PIMPED: - ❑N. CONCRETE PEDESTAL■ dIRUR:❑Yoo 4N'R s <br /> APPROX.DVTN �/ F LOCK"CHESTER SOXN'TOVE PIPE 5 <br /> IROPOS[O CONSTRVCTIONIORIUINo METHOD: MUD ROTARY_AIR ROTARY AUGER CAME OTHER <br /> 1 HF4SY CERT WY THAT I HAVE PREPARED THIS APR1CAT"AND THAT THE WOW WILL BE DONE N ACCORDANCE WfTH SAN JOAOUN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUN COUNTY.NOME OWNER OR UCMSEO AGENT'S SIGNATURE CERTIFIES THE MUDWSNO:'1 CERTIFY THAT M THE"WORMANC!Of THE WORK FOR WHICH <br /> THS PEMIT M tSSUED,1 SHALL NOT EMPLOY PERSONS M,SJECT TO WORKMAN'S COMPENSATION LAWS OF CAl1FO . CONTRACTOR'S""No OR M/R-CONTRACTNG SIONATUIIE CERfNES <br /> THE FoLLoWNO: 'I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH TWO PERMIT H ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORIONAN'S CGMPDNSAIION LAWS OF <br /> CALIFORNIA.* tf AMIOANT MUST <br /> /C/'/}//LLL- HOURS N ADVANCE F011 ALL MOIM®D*1\SPSOTTIOONSQAT 1MSI AN-24".COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> S*-a X V f C. /I l`=/AE/WE' TM. <br /> PLOTPAN 0—to so"S..I. I. <br /> 1.NAME/OF ITERE <br /> FTS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION Of/OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OVTLINE Of THE PROPERTY,GIVIIO OwmvoNs AND NORTH DIECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> G.DIMENSIONED OUTLIW6 ALIO LOCATION OF ALL EXISTING ANO PFOMOM S.LOCATION OF WELLS VMM N PAMO OF ONE MINDMD FITY FT. <br /> STRUCTURES.NCLUOM COVERED AREAS MUCH M PATIOS,DRIVEWAYS,AND WADS. ON THE PROPERTY OR ADJOINING AOPERTY. <br /> ..... <br /> /Vµ <br /> PAYMENT" —� <br /> RECEIVED .. <br /> MA <br /> kS j!E'f JOAdUIN QOU= <br /> H .LT ..._ <br /> DEPARTMENT USE ONLY " on/1810N <br /> MY.ul S n I.G Sr <br /> w.I l LPf P IroP..n.n Br aR. <br /> DIt—YrF D.I. <br /> - o-Rou E u R - I C�-!K-wr- <br /> ACCOUNRNO ONLY: NDE FACP <br /> PE CODES FEE INFO MOUNT RBATIVO CHEC ICASH RECDV[O SY DATE POMT12"IVICE"GMT NUMSER INVOICE <br /> '}3• , I� �0 31 I� 5 98' 0 5 5 1 a <br />