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` APPLICATION FOR WELL/PUMP PERMIT � -S�h `F <br /> { NOV ? 3 1998 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION c 3� <br /> urvfY 304 EAST WEBER AVENUE, STOCKTON, CA 95202 �t <br /> '�•".�.4i}i SERVICES {209) 468"3420 Y. <br /> RON-REFUNDARE PERMIT EXPIRES 1 YEAR FROM HATE ISSUED <br /> (Co mplefs IR Tllp&atsl <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUTN COUNTY FOR A PERMIT TO CONSTRUCT ANDAR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITIL CHAPTER 9-1115.9 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.fNV?RONMENTAL HEALTH DIVISION. <br /> L' �� L" C <br /> ' r �7 i� - <br /> JOB AOORESS/OR AIPyNNO J v _J L i 7- CITY J-"T=C �. PARCEL <br /> 1L <br /> OWNER'S NAME Acom .~S ;I ZG 6 - <br /> PHONE I <br /> CONTRACTOR �+C JET` a�„L.�,Juy-:, {�-i -..= 1 F'rMf.±- C� ADDRESS. .�"r1Tr_ rt_.�(,kr} r'f►j i��.� -LICr J :02 2'rmNE I -3r3 -G 54 <br /> ADDRESS <br /> SUBCONTRACTOR <br /> ���, �^ �S•t i�.i _ �'1-�11E'1'.-J t.! .3-'�- `1�]i.' .Cl��:�1�•J- !!Cr �� � PHONE! r Z�q <br /> TYPE of WELLIPUMP: ❑ NEW WELL 0 REPLACEMENT WELL O I.TOHITORNG WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR © CROSS-CONNECT'REPAIR ❑ VAP'QR EXTRACTION WELL I <br /> ❑Naw❑Repay H.P. DEPTH PUMP SET .. FT, FIRST WATER LEVEL O <br /> !TYPE OF PUMP? <br /> ❑ OUT-0F•SERVICE WELL .❑ OEQPMVSICAL WELL 1P SOF`SOM <br /> .0 DESTRUCTION: <br /> INTENOED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - A <br /> © INDUSTRIAL ©OPEN BOTTOM DIA.OF WELL{XCAVATION OIA.OF CONDUCTOR CASINO p <br /> O DOMESTIClPRIVATE ❑GRAVEL PACKNUE TYPE OF CASING/STEEI/PVC OIA.OF WELL CASINO O <br /> ❑ PUBLIC/MUNICIPAL D N DEPTH OF GROFJT SEAL SPECIFI ATION q <br /> ❑ IRR{OATgN/AG I - GROUT BEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED:❑Yea ❑Ne CONCRETE PEDESTAL SY DRILLER;O Yw ON. S <br /> APPROX,DEPTH LOCKING cHEeTER BO7R/STovE RPE S <br /> PROPOSED CON9THMCTIONIORILlD1G METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9ESY CERTIFY THAT I HAVE.PREPARED THIS APF�ICATWN AND THAT THE WOR(WILL,BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE BAN JOA OURV COUNTY, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH - <br /> i THIS PERMIT to t8 ,I SHALL HO OV NS aUEJECT TO WORIWIAWS COMPINSATTON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONI'RACTRlG 81ONATURE CERTIflE6 <br /> THE FOLLOWING: CE F T IN ANCE OF THE WORK HI <br /> FOR WHICH TO PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUWECT TO WORITIRIAN'O COMPOIGATION LAWS OF <br /> CAUPORMA." T APP[JCAN. T C W ADVANCE FOR ALL REflURSIO INSPECTION$AT 1""4410-3127Rk' <br /> . COMrIE DRAWING AT LOWER AREA PROVIDED. <br /> elpned 1 TNN <br /> PLOT PLAN 10,aw to Seale Seal* 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. - 1, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVM DIMENSIONS AND NORTH DIRECTION. _ EXPANSION OF SEWAGE DISPOSAL SYSTEMB, <br /> 3. DIMEPISIONED OUTIINFS AND LOCATION OF ALL EXMrRNO AND PROPOSED - S. LOCATOR OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVETED AREAS SUCH AS PATIOS,OWVEWAYB,AND WALXS. ON THE PROPERTY oR ADJOINRRO PROPEITTY. - <br /> ' <br /> DEPARTMENT UdE ONLY <br /> APPileallen AeeWled by-- +VC - Dna l A as Y-v. <br /> Mout"peetw.By Date Pump 1 oveetlen Sy Data <br /> k <br /> 13-mmWlen inavaetien Br <br /> Dote <br /> ,/j - <br /> ACCOUNTING ONLY: NOl FAC! <br /> PE CODES FEE INFO AMOUNT ROWTTED CHE ASN RECBVED■r DATE P90MTfO"mce REQUEST Ntme"t INVOICE <br /> 3so� 91r,ot <br /> Pub yeatth Serv.-'=rlviro.173(1197) <br />