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4 <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 OCT 2 7 1998 <br /> (209) 468-3420 <br /> --)N[OFN <br /> - -i A L <br /> -,v i-�, <br /> NON-REFUNDABLE-PERMIT EXPIRES I YEAR FROM DATE ISSUER <br /> (complete In Tirlplivatel �ERJVA ISERVICES <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE VMW DESCRIBED.THIS APPLir-A-riciP4 is MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115,3 AND THE EN8 OF AN JOAQUIN COUNTY PUBLIC HF4LTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ;r I <br /> JOB ADDRESMA APN# D4 , CITY 571cr-" PARCEL SIZE/APHI. a22 <br /> ADDRESS 2, <br /> OWWER's NAME f—k PHO 0 7 <br /> COMPACTOR ADDRESS. <br /> -b�[k7— & - <br /> AUS CONI'MAC ton j; � 51a ADMSS.AR3�( f2a!4 LIC# <br /> TYPE OF PYMF- 621". u 13 REPLACEMENT WELL P(MONITORING WELL# OTHER <br /> -WELLL <br /> INSTALLATION 13 WELL SYSTEM REPAIR E3 cnoss-cormtc-r nepmii 0 VAPOR EXTRACTION WELL I j <br /> 0 N.0 ASPOlf M.P. DEPTH PUMP SET-_FT. FIRST WATER LEVEL 0 <br /> (TYPE OF PUMPI <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL 8 ❑ "Olt.BORING <br /> 13 vewrRucTION, <br /> :j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INMBTMAt BOTTOM 13M OF INELL]EXCAVATION If DIA.OF CONDUCTOR CASING bt� <br /> L3 DOMFSTICIPRIVATE Ei 7F.A.PACK1812E TYPE OF CASFNGISTEE CIA.OF WELL CASING <br /> ❑ PIJBILICIMUNIC[PAL ❑QmVE" <br /> DEPTH OF GROUT SEAL SPECIFICATION <br /> !PVGATION/AG ❑OTHER GROUT SEAL INSTALLED BY OROUT BRAND NAME E <br /> GROUT SEAL PUMPED: El Yoo 14. CONCRETE -[3v. 0". S <br /> APPROX.DEPTH LOCKING CHEST OVE PIPE <br /> T9- <br /> PROPOSED P--TRI-t'TlnP'rl)FV-IJPM METHOD-. MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK%MLL BE DOME IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAW@,AND RULES AND <br /> REGULATIONS Of THE BAN JOAQUIN COUNTY. 1401,41!OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING''I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR W141CH <br /> THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WOMMAN-4 COMPENSATION LAWS Of CALIFORNIA.- CONTRACTOR'S WRING OR BUD-CONTRACTING MHATUIRE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERM11T 10 ISSUED,I SHALL EMPLOY PERSONS BURJECT TO WOFWAAN'S COMPENSATION I.Aws OF <br /> CALIFORNIA.' T,; APCT�MUSYAA SPJFTIONS AT 120#1 <br /> , 7 1 <br /> if NO ADVANCE ADVANCIF FOR ALL REQUIRED III Iva-vi". COMPLETE onm~�AT LOWER AREA PROVIDED. <br /> ftned k 14 Tills RL Y� Date ZO—Z7—/ <br /> Q/ <br /> PLOT KAPI Wrow to Scolol goals <br /> 1, NAMES OF STREFTO OR ROADS NEAREST TO OR BOU"D"M THE PROPERTY. 4. LOCATION OF"OUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION Of ALL EXISTING AND PROPOSED S. LOCATION OF Wlti@ VAtHIN RAMS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES.INCLUDING COVERED AREAS OWN AS PATIOS,DRIVEWAYS,AND WALK6. ON THE PROPERTY Oft ADJOINING PROPERTY. J <br /> ........................... ...... ...... ........ ...... <br /> ................... .. ..... <br /> .... ... . . .................... ....... <br /> ........................ .... ....... ....... <br /> .. <br /> ... .... <br /> 07t <br /> ....... ....... <br /> O"AATMINT UZI!ONLY <br /> Appftovlon Ao*aptod 81, Dole—q0, —Am <br /> Omit Ir"Peetlen my Data PL—v Impaction By <br /> Doti <br /> Vestrmtte"Impaction a Doi@ <br /> ACCOUNTING ONLY: FACP <br /> 10-f-covild TEE two AMOUNT REMITTED CHFCOICAS14 RECEIVED MY DATE P13 T/NERV[CE REQUEST NUMBER INVOICE <br /> 7--�5" <br /> 3-7 <br /> IE <br /> Pub Health Serv.-Enviro.173(1197) <br />