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I � U r <br /> t <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBNI'leb Fr TrIpNeate) <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DE8Cr4ffO.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-11 X118.3 /�/T(H)Ey�STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION AAQr— <br /> OWNER'S <br /> JOB ADDRESSOR APN/ Arm ,�+ l n CITY t CA- PARCEL S12E/APN/NAME /� `S / N r2 ADDRESS Qc,PHONE I (% <br /> CONTRACTOR O d ADDR ESS C�136 <br /> SUB CONTRACTOR ADORES(Lnti LICJ—►/ J PHONE <br /> TYPE OF WIELL/PINMP: 9 NEW WELL ❑ r1EPLACEww WELL ❑ MGNITomm WELL. ❑OTHER LL "..- <br /> ❑ INSTALLATION ❑WELL STEM REPAIR ❑ CRO89-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> RYPE OF Pl/M% <br /> 9N.w❑Rap* H.P. DEPTH PUMP argdw.FT. FIRST WATER LEVEL O <br /> ❑ OUT-oF-sm ICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL sown B <br /> ❑DESTRUCTION' <br /> INTENDED USE ixmmm CONSTRUCTION SPECIFICATIONS N A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM j DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> Jv DOMESTICIP IVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/8TEELRNC DIA.OF WELL CASINO <br /> ❑ PUBLIC/MUNICIPAL ❑ORVEN DEPTH OF OROUT SEAL A SPECIFICATIONO R <br /> ❑ MOAT10N/AG ❑OTHER GROUT SEAL INSTALLED BY 124 , GROUT BRAND NAME 14,11 E <br /> ❑ MONITORINGn / GROUT SEAL PUMPED:gY» ❑N. CONCRETE PEDESTAL BY ORILLER:9tY.. ❑N. S <br /> APPROX.D."—j 6 D LOCKING CHESTER BOX/STOVE PIPE ,,lS <br /> PROPOSED CONSTRIICTONIDR-I METHOD: MUD ROTARY_ AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TINT FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUNJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUGCONMACTINO SIGNATURE CEIITWIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE MUST CALL. URS IN ADVANCE FOR ALL REGUNED INSPECTIONS AT 12081400-9420. COMPLETE DRAWING AT LOWER AREA PROVID D. <br /> �p 4 <br /> Stroll Title f• C. Dtl. <br /> PLOT PLAN(Draw t.S..lel Se.N 't. <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL 8Y8TEM OR PROPOSED <br /> 2. OUTUNK OF THE PROPERTY.GIVING IM <br /> DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DO SAL SYSTEMS. <br /> 0. DIMENSIONED OVnwn AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTUREB.INCLUDING COVERED AREAE SUCH AS PATIOS,DRIVEWAYS,AND WALKS. fMr7lE#IpFER71rSlMLApJpNIRNS P1 Pt1liFY. '' <br /> . i.. <br /> i.. <br /> .. <br /> V <br /> \r� <br /> 5 .... <br /> _. -. .. .. .._. .. ..._ _. <br /> . .. ( <br /> P ME <br /> NT <br /> R. CEIVFn- <br /> .. <br /> DEC 31 X998 <br /> SAN JOAOUIN COON I'Y <br /> PUBLIC HEALTH SERVICES r <br /> ENVIRONMENTAL HEALTH DIVIS10t+ <br /> DBARTMEIIT USE ONLY ``� ,i^/�—j _ <br /> AppNe tlen Aeeepted By • O.t. J I, V Ar» v ,( <br /> Gr.ut 1n.paotlen By O.t.���Pump lropeetten By D.» <br /> a � <br /> Denretlen In.p.etien By note <br /> Cmnms.t.• <br /> ACCOUNTING ONLY: AO/ I FACO <br /> PE CODES FEE INFO AMOUNT RVATTED CHECIU/ MN RECEIVED BY DATE PEIRMIT/SERVICE REGUEBT NUMBER INVOICE <br /> 3�(a 1%c) t -- t6 <br /> ago 105c) 5-0, az) 1 <br /> Pub Health Serv.-Enviro.173(1/97) <br />