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APPLICATION FOR WELLIPUMP PEP <br /> SJOADUIN COUNTY PUBLIC HEALTH SICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 ORIGINAL <br /> NON-REFUNDABLE PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> mempistE in YI OCS AEI <br /> APPLICATION 49 HERE BY MADE TO THE BAN JOAOMN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRSED,TIPS APPLICATION 18 MADE IN COMPLIANCE WIri1 SAN <br /> JOAOUIN COUNTY OEVELOPMMENT TITLE.CHAPTER 9.1 11 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICED,ENVIRONMENTAL HEALTH DIVISION.JOB ADOREGSMR APNI l J 3 I gEF- C k A ry 4 2-e —CT' J a[, PARCEL BIZFfAPN8 <br /> y 4" .111 <br /> �• II__ i, T I,� j10 �} t <br /> OWNER'S NAME `ICC N I .11 (.(Cho'H t t -;0 illd114c K 1 ADDRESS IVa V`t I� i -e �+�. 1 -0C \ PHONE R 73 1-'7O7 <br /> CONTRACTOR r.H VCN C+d 40' Ian'snim-evils i ADDT�BB.'i00 AI IWtl-foo Wa 1JC/6430;)-1 PHONEt46 ( 1006 <br /> BUB CONTRACTOR AbORE88 —� IHC/ PHONE <br /> TYPE OF WELLIPUMPc ❑ NEW WELL ❑ REPLACEMENT WELL 11 MONITQRING WELL Iy ❑ OTHER ' <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSG-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r J <br /> ❑New❑Repdr H.P, DEPTH PUMP GET FT. FIRST WATER LEVEL O <br /> ITYPE OF PUMPI J ? <br /> 0GUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL A � GOAL BORNO th B <br /> ❑DESTRUCTION: <br /> INTENDED UiE TYPE OF W CONSTRUCTION SPECIFICATIONS+ A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM 7 OIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ OOMESTIC1rRIVATE ®GRAVEL PACKIBIZE 3 TYPE OF CASINGISTEELIPVC ?V C- DIA.OF WELL CASINO b <br /> ❑ PUSLICRMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL LJO r T•Y- -__ SPECIFICATION Sa: - 4 0 R <br /> ❑ IRAIGATKINIAG ❑OTHER GROUT SEAL INSTALLED DY M IA i t GROUT BRAND NAME O i tt Ila E <br /> tA MONITORING I GROUT SEAL PUMPED: ®Y. ❑He CONCRETE PEDESTAL BY DRILLER:❑Yw ®Ne s <br /> APPROX.0EYTH 6 5 � 100 LOCKING CHESTER BOXMTOVE PIPE �� s <br /> PROPOSED CONfTRUCTIONAMLLINO METHOD; MUD ROTARY AIR ROTARY AUGER �CABLE OTHER <br /> I HMBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUI14 COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S 81ONATURE CERTTtFFE8 THE FOLLOWMI.'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IG ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-8 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HRUNG OR SUS-CONTRACTI,SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 MOVED.I SHALL EMPLOY PERSONS SUBJECT TO WOnMWAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED tNSPWTIONS AT[..14,0,3.". COMPLETE DRAWING AT LOWER AREA PROVIDED. ' <br /> [� <br /> TId•-)9L4 ea 5 rY a Ff r�"OlOxF� bn• 3 ' ` C!1 1 _ <br /> PLOT ALAN Iprew to Soelol Sade <br /> 1. NAMES OF BTREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. - 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVINKI OMEN NO AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DBMENBIQNEO OUTLRHF.S AND LOCATION OF ALL EXW NW AND PROPOSED S. LOCATION OF WELLS WITHIN RAOMS OP ONE HUNORED fIFTY FT. <br /> STRUCTLIREB,INCLUOING COVERED AREAS SUCH A$PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT UBE ONLY <br /> Appustlen Aee"Ied By Det* <br /> Grout hwpmtl r By Outs Pump hwpeellen ey <br /> 0-mmtlen lrwpxtlen By <br /> Cnment0 'J'e* � .tfY AeW <br /> 1�^'�• I4 / <br /> oo <br /> ACCOUNTLNO ONLY: Aro/ FACE <br /> I <br /> PE CODES FEE INTO AMOUNT REMITTED CHECKIfCASH RECEIVED BY DATE ►HUMITISF7MCE REOUEBT NUMBER INVOICE <br /> Pub Health Sem.-ERviro.173{197} <br />