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s APPLIC ION FOR WELLIPUMP PERMIT + � <br /> SAN JOAav' )LINTY PUBLIC HEALTH SERVICES <br /> ENVlh-..IYlENTAL HEALTH DIVISION <br /> P 0 BOX 389,445 N.SAN JOAQUIN ST„STOCKTON,CA 96203388 <br /> 1203)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Complete in Tripllate) <br /> APM.ILATWN 4S HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMITTO CONSfILICT AND10R INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE M COMPLIANCE HATH SAN <br /> JOAQUIN CO UM' DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANOAROS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIAONMENTAL HEALTH DIVISION. <br /> JOBADDmssioR APNN. 741 N• Dietrich Rd _CITY_. jJITITj PTI/pPf PrC PARCEL SREmw 7,2- <br /> OWNEWS NOME (James DeMartini ADORE66P•0e Box 431 ,Linden y„D„E, <br /> cowmwTOR Purviance Drillers Inc. ADDREss P.O.Box 64,Linde-uc■377923 PHDNE,T887-3554 <br /> SUS CONTRACTOR - ADDRESS UCR PHONE f <br /> TYPE OF WELLIPUMP: 1 NEW wELL ❑RERACEMENT WELL ❑MONITORING WELL 0 ❑OTHER <br /> 11 INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑1111911 EXTRACTION 1111"1 J <br /> T,I <br /> (TYPE DFF PUMP( A New 11R"lr H.P. 3 Hp DEPTH PUMP 8ET.9 s$r. FIRST WATER LEVEL O <br /> P <br /> ❑OUFaFSERVICE WELL ❑GEOPHYSICAL WELL f ❑ 608.BORING B <br /> ❑DESTRUCTION:'. � <br /> LKIENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> 1rL'-J1I INDUSTRIAL ©OPEN BOTTOM IIA.OF WELL EXCAVATION_ 12"____ DIA.OF CONDUCTOR CASINO 11 3 D <br /> IJ DOMESTc m ATE ❑GRAVEL PAC"IZE TYPE OF CASING/6TEELIPVC Stan, DUI.OF WELL CASING 6 5/8 D� <br /> ff ❑Puuw)mUNYCIPAL 11 DRIVEN Do"OF GROUr sm -u-icAm. _ _1.3 4 R <br /> ❑lwaAmwAG ❑OTHER OROuT SEAL INSTALLED BY PnT GROUT BRAND NAME E <br /> ❑MONITORING 4j�' GROUT SEAL PUMPED: Vs ❑Ne CONCRETE PEDESTAL BY DRILLER:❑VM [IN. 8 k <br /> APPgX.DFPFiI .�1`l (�` LOCKING CHESTER BOXISTOVE PIPE g C <br /> PROPOSED CON;LIM1G. LL'N.METHOD: MUD ROTARY XX AIR ROTARY AUGER CASLE OTHER <br /> i HF9EBY CERTIFY YHAT I HAVE PREPAREb TH1S APP.ICATION AND THAT THE WORK WFLL BE GONE M ACCOROANCE WITH SAW JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES MIO <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR UCEN6EO AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHiC <br /> THIS PERMIT IB Is6Aum,I SHALL NOT EMPLOY PERSONS susJECT TO WORXMA vs COMPEIEATION LAWS OF CAUFORNIA.•CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFI tS <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORX MAN't COMPENSATION LAWS OF-' <br /> CALIFD . ALL 24 HOURS IN ADVANCE FOR ALL RECURW M11IMTR)Ii8 AT(20BI 4U-2422.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> `�t 1'4A z��ctot-) Tl,le CQrpr)ratP gerrF-tary D.r. <br /> RAT RAN IDraw Me Salol Sella •to <br /> NAMES OF ST I S OR ROAOW NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ' <br /> 2.OUTLINE OF THE PROPERTY,GING DIMENSIONS AND NORFH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.OtMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RAXUS OF ONE HUNPRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALLS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ..... ...... <br /> ........ <br /> ... ....... ............... <br /> c..... ....... ........ ....... ....... ...... ..... <br /> ]....... ............ . ..... ...... ....... ....... ........ . ............... <br /> ......... ....... ...................... .... . ... .... <br /> :.,,. ... . <br /> ,,.. <br /> .... ....... <br /> .. ... .. . <br /> ..... <br /> .... <br /> .......... .... ...... ..... ......... <br /> ..... <br /> �_ .... ...... .... .. ............. <br /> .... ....... ...... <br /> �� <br /> ..... ..... .... .. ..... <br /> ..... ....... .............. ...... <br /> jjI ............. <br /> ,,....,.. . ....... @............ <br /> mos, <br /> "..... „ S <br /> ............ <br /> ...... ..... <br /> . ,... : <br /> ..... ...... <br /> 1�} � ............ <br /> ........... ....... <br /> ....... <br /> .. <br /> ... <br /> .... ..... <br /> .... ...... <br /> ........... <br /> ....... ........ ........ <br /> .. `.. <br /> .. � <br /> 'e <br /> . JUN-1 9 �996 <br /> . ... .... .. .. Q hsC ILj-A, . ..._ . <br /> SAN JUA <br /> O�TE3L3c 1��4a_Ti�.sF�lrlr�:�. 1 <br /> f <br /> DEPARTMENT USE ONLY <br /> AppElcalien Aaapted By F / Area 1 <br /> Grout I-P-0-BYI`�.... .._(ate_'7-f 5-`t L Pump Ir p.—BY c4m <br /> DaPhueHwl hmpectl n BY �1 �e <br /> Cammanle: I t <br /> ACCOUNTING oN Y: - AIDE PAC/ <br /> PE CODE8 INFO ..REMITTED Af.'ASH RECEIVED BY DATE I4 XME REQUER NUMBER INVO1IC�E <br /> l yj <br /> /OR U� <br /> V <br />