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0 Y7'� L -"j <br />oos-y?o - <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NON-REFURORBLE PERMIT EXPIRES I YEAR FRIM DATE ISSUED <br />mampYN In TrIFRaMI <br />APPLICATION IS SIM IY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDUOR IN6TALL THE WORK DESCRIBED- THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTS' DEVELOPMENT TITLE, CHAPTER 9-11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH wAMON. <br />JOB ADORESSIOR AM-$ � � _ � � c.� *-/ �J �� � C' /if 1- CRY T.C= CY PARCEL 9120AP!1/ <br />OWNER'S NAME-L�'y % 5 II g 7:Vj 0 % ADDRES9 / U V �' �_►iCx` iGN� '�Ti�w P'rIONE s �__ .�') <br />_-��� 425 _ _ .� <br />_r <br />CONTRACTOR - 1 L _ I+L Y "L -' , _ AbbRE88 -5- 671 T� 5- /�f�+ UCP 1 d � ` :3 pmHE I <br />SUS CONTRACTOR ADDRESS "CP PHONE t <br />TYPE OF WELL/PUMP-. ❑ NEW WELL ❑ REPLACEMERrT WELL ❑ MoNrronim WELL a I] OTHER_ <br />r ❑ tNSTALLAlrMN ❑ WELL SYSTEM REPAIR ❑ CROS"OHNECT REPAIR ❑ VAPOR VX3RACTION VMELL <br />�3 ❑ Nw- ❑ Rolml, H.P"! _ DEPrN PUMP SET FT. FIRgT WATER LEVEL O <br />(TYPE OE PUMP <br />- -- -� ❑ OVT-OF, SERVICE WELL ❑ GEOPHYSICAL WELL P ❑ SOIL. SOMNO g <br />❑ OEsrRDCT1gH; - �- _ "'' I `-'���C2''<-Z.<v. - _ C-L'jk sir <br />INrETDED USE TYPED CON5TRUCTION SPECIFICATIONS A <br />❑} INDUSTRIAL ❑OPEN BOTTOM DIA. OF WELL EXCAVATION !AA. OF CONDUCTOR CASINO o <br />1^J DOMESTR:ry`WVATE ❑ GRAVEL PACKISIZEy_ TYPE OF CASINOISTEELIPVC DIA. OF WELL CA1511410 p <br />❑ P1BLICAAUNICIPAL ❑ DRIVEN OEPTH OF GROUT SEAL _ SPECIFICATION R <br />❑ IR IGATIONIAG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br />❑ MONHOP P40 GROUT SEAL PUMPED= ❑ YM ❑ No CONCRETE PEDESTAL BY DRRLERt ❑ Yw [IN. S <br />APPROX. DIF"M LOCKING CHESTER BOXMTOVE RPE S <br />PROPOSED CONtTRUCTI4NIONL11N0 METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK W4L BE DONE M ACCORDAWE VATH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OVVWR OR LICENSED AGENT'S 11110NATURE CERTIFIES THE FOLLOWING- 'I CERTIFY THAT W THE PEWORSAANCE OF THE WORK EOR WHICIN <br />THIS PEFlMrr IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORIWiAN'S COMPM*AT1ON LAWS OF CA.LIFOFMA-' CONTRACTOR'S HIRING OR BUS-COHTRACTtNG SIGNATURE CEIRIFIE■ <br />THE FOLLOWING_ ' I CERTIFY THAT IN THE E OF THE WOM FOR WHICH THIS PERMIT IB 186 M0. 1 SHALL EMPLOY PERSONS BURIECT TO WORIWAN'S COMPENSATION LAWS OF <br />cwEowlA.; T%L±�f/AFPUC . MIHi CIKL� 2�4/!1/i� Ili ADrFANCE FOR ALL 1e(�OUl1� MPFpO NS AT 12fAl 40S snit. Cow1ETE DRAWING AT (OWER AREA PROVIDED. <br />� <br />�1�� <br />Slprnd 7�KLfff//V -G-C- �-�J'r✓' �/ .. }�lY. R� <br />F <br />v <br />PLOT FLAN Ndirw 1s Se.I.I Eery ' to <br />1- NAMES OF STREETS OR ROADS NEAREST TO OR BOUNORM THE PROPERTY. n, LOCATION OF HOUSE SEWAGE INW09AL SYSTEM OR PROPOSED <br />(Ti <br />2. OUTLINE OF THE PROPERTY, OWING DIMENSIONS AND NORTH DIRECTION. EXPANSIMN OF SEWAGE DIBPOBAL SYSTEMB- <br />3. 010MENSIONED OUFUNES AND LOCATION OF ALL EX101- FIO AND PROPOSED B. LOCATION OF WEDS VVF MH RADIUS OF ONE HUNDRED FIFTY FT- <br />BTRUCTUHES, NVCLUWNO COVERED AREAS SUCH AS PATIOS, ORNVEWAYS, AND WAUcs, ON THE PROPERTY OR ADJOINING PROPERTY. <br />ri <br />ApplleNlert Aeeepled <br />G—m i—peeelen BT_ <br />O—w.tyn lmpP llv+ <br />DEPARTMENT LR! <br />um <br />Dote Pp Inepeeelen <br />ONLY <br />Det• A,. <br />By <br />Deep <br />Pub Health SerY. - Ebviro. 173 (1197} <br />v <br />