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i 1 <br /> 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) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complett In TrlpUo&tal <br /> APPUCATKIN 19 HEM BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANEUGA INSTALL THE WORK DESCRIBED.Title APPLICATION IB MADE IN COMPLIANCE WIT11SAN <br /> JOAMIN COUNTY DEVELOPMENT TITLE.CHA <br /> 11PTER 8-1115.3 AND THE\STANDARDS OF BAN"AMIN COUNTY PUBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDREe9roR AFNFY� IrL c�yS FC Lq t>a..rk Vr. CRY LVI Q,,, Fc� '/U <br /> 1 1 PARCEL BIZE/APNI O.tl Q�l-19Ip <br /> OWNER'8NAME IS6 L-a6S L,..1. ADDRESS 3Coe1 Pc1..csaYL �-Jo SgKEy C..%�r4 <br /> 11 y• PIONE14GK'_/7.1' TLC�j <br /> CONTRACTOR_J}TC ADDRESS 1117 Lonc pall l{Wrl Moi UCE PHONE/Z4S.S7R"22il <br /> SUBCONTRACTOR_i"rS�LI ENV`fOv.YYVa.n�) ADDRESS 3°IS ShGnS �L4K t10E 683$GS PHONEP2Q9'772-3S�D <br /> Ic11..Y1 P�`K'S .LA <br /> TYPE OF WELL/PUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL E ❑ OTHER <br /> V INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSb ONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑New❑R"Wr N.P. DEPTH PUMP BE —". FIRST WATER LEVEL O <br /> (TYPE OF PIMP) �. <br /> ❑ OUT-OF SERVICE WELL ❑ OEOPHYSICAL WELL I or Solt 80NNO Z k 1 S r , 11 Y14, B <br /> ha�•.n S Lo 1J <br /> ❑DESTRUCTION: 9�s } t J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& A�4 I <br /> ❑ BIMSTRIAL ❑OFEN BOTTOM DIA.OF WELL EXCAVATION ^' 7_�Rwc.... DIA.OF CONDUCTOR CASINO g/-4 D <br /> ❑ DOMESTICPSIVATE 11 GRAVEL PACKMIZE TYPE OF CASIMMTEEI/PVC NA.OF WELL CASINO N/- O <br /> ❑ MBHCRAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ 1-k Lo 1I S c-} SPECIFICATION ,AJ�� R <br /> ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME Nth E <br /> ❑ MONITORING r ` GROUT SEAL PUMPED: ❑Yr WN. CONCRETE PEDESTAL BY DRILLER:❑Y.. l,lLle s <br /> APPROX.DEPTH S 1 S 1� LOCKING CHESTER SOX/STOVE RPE „`` 11 \\ S <br /> PROPOSES COMIMUCHONIDPLUNO METHOD: MUD ROTARY AIR ROTARY AUOER CMLE OTHER U I rA 4 I�yb <br /> 1 HEREBY CERTIFY THAT I HAVE FEPARM THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAMIN COUNTY ORDINANCES,STATE LAWS.AND RULES ANO <br /> REGULATIONS OF THE BAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT M THE PEWORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED.1914ALL NOT EMPLOY PERSON@"ACT TO WORKMAN't COMPENIATION LAWS OF CALIFORNIA.- CONTRACTOR-8 HIRING OR BUS-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN TIE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSON8 SUBJECT TO WORISMAN'S COMPENSATION LAWS OF <br /> CAUTORNIA.- THE APPLICANT MUST CALL 24 HOURM IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1208)40041433. COMPETE DRAWING AT LOWER AREA PROVIDED. <br /> 91'1 x ” TIB. LALL.45,91i fd(�,LLL�I—o... <br /> MOT PUN mr..y t.SeH.I 9e.1. 1 't. 1$V <br /> 1. NAMES OF STREETS OR MADS NEAREST TO OR 8OUNDING THE P10PITTY. 4. LOCATION OF MUSE SEWAGE DMFOSAL SYSTEM OR prIDMI ED <br /> 2. OUTLINE OF THE PROPERTY,OIVINO DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENINO ED OUTLME&AM LOCATION OF ALL EXISTING AND P OMSED S. LOCATION OF WELLS WFTHfN RADIUS OF ONE HUNDRED FIFTY R. <br /> STRUCTURES,WLUDM COVERED AREAS SUCH AS PATIOS,DPVEWAY8,AND WALXS. ON THE PROPERTY OR ADJOINING FROMRTY. <br /> AUCVEGROUND <br /> � TRANSFORMERS � � � • � �r"je� <br /> o % (_pCape,-8 <br /> I MW-5 <br /> E MW-' MAIN BOUGILDING ��.` gyOGST <br /> L OXYGEN TANK <br /> • ORif,,. <br /> L ASPHALT COVERTANK <br /> EDFORM <br /> L PARKING WAS <br /> TIN PLATE WASTEWATER , <br /> '1 UFT STATION • AREA <br /> (SUMP) LS TREATMENT / LINE <br /> EXISTING WASTEWA CW- COMPOUND (� <br /> TER ,L'� / ♦.r MAINTENANCE <br /> TREATMENT SYSTEM \-� / UMP STORAGE m STORAGE <br /> FORMER WASTEWATER C/ / sG PARKING <br /> TRE>FMENT SYSTEM .� i ABOVEGROUND PROPANE <br /> �.` • ANK`� <br /> g / TANKS ♦ MW-3 544 <br /> EMPTY ORUM \ // \ i <br /> I,5 / STORAGE COMPOUNDD% Y 'P <br /> ON ` i/ COMPRESSED % • ^'/m FEP'ICE <br /> / GAS CYLINDERS <br /> / ` AIR FILTP <br /> ATION,ti <br /> YSTE <br /> CHEICAS% M, STORAGE S <br /> ^S <br /> CRAG % ARCHIVE M <br /> � <br /> Fa� STORAGE ARF <br /> A4SHC <br /> MATERIAL STOP <br /> COL <br /> WEu &141 STORAGEi4z% ^�\ MACHIP <br /> CEWEKE HYTROL CONVEYER �TnPnrc <br /> DEPARTMENT USE ONLY <br /> Applle.11en AaeplM BY ��J ttMr�`�\ ES <br /> A7- <br /> meal In.p.cllen eF oHe FvnP IraP:gen By Dn. <br /> O-tr,cuen Imnxlbn By D.,e <br /> }� �j <br /> ce,nin.xr D \ <br /> ACCOUNTING ONLY: AIDE FACE <br /> PE CODES FEE INFO AMOUNT REMITTED CHICF ASN RECEIVED BY DATE PDIMITISERVICE REQUEST NUMBER INVOICE <br /> 0�v 617 111& <br /> Pub Health Sew.-Enviro.173(1/97) <br />