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ls APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES °;, • . a ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 FEB 2 2 1990 (209) 468-3420 TI NOX-REFURDA BLE-PERMIT EXPIRES i YEAR FROM DATE ISSUED , > ' {Complete In TrlpR1; eete) ` ,_I",Yjr�! ;- _.s ,`� APPLICATION 19 HERE BY MADE TO``T'HE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 19 MADE 1N COMPLIANCE WITII SAN JOAQUIN COUNTY DEVELOPMENT Ta LE.CHAPTER 9.1 115.3 AND THE STANDARDS OF SAN JOAQUIN CGUI 34CALTIO SERVI 0,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESSAOR APNN CITYyl PARCEL SIZFJAPN# OWNER'S NAME ADDRESS PHONE I CONTRACTOR ADORES _y , III. {ONE R '+7 41 1 SUB CONTRACTOR ADDRE68 6 LIC! PHONE TYPE OF WELUPUMP; ❑ NEW WELL ` AEPLACEM£M WELL ❑ MONITORING WELL 11 ❑OTHER 11 INSTALLATION CI WELL SYSTEM REPAIR ❑ CHOBS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL I 1 � ), ❑PAP& H.P- DEPTH PUMP BET FT. FIRST WATER LEVEL G fij'pE OF PI � OUT-0F•RERVICE WEL © aEOpHYSICAL WELL A' ❑ SOIL BORINO DESTRUCTION-.. / I TENDED USE TYPE O CONSTRUCTION SPECIFICATIONS A ❑y IVDU RIA- PEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D LI DOME9TICIPRIVATE ❑GRAVEL PACKMIZE TYPE OF CASINOISTEEL/PVC DIA.OF WELL CASING ❑ PUSUCIMUNICIPAL ❑^t DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME —swe ❑ MONITORING GROUT SEAL PIMPED: ❑Yr No CONCRETE PEDESTAL BY DRILLER:❑Yee. []No S - APPROX.DEPTH LOCKING CHESTER B XISTOVE PIPE PROPOSED CONSTRUCTIGHIMMLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE I' OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REQULATIONS OF THE SAN JOAOUWCOUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEWORMANCE OF THE WORK FOR WHICH TM9 PERMIT 19 ISSUED,R SHALL NOTEMPLOY PERSONS St1BJECT TO WORKMAN-$COMMIATtow LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR OUN-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: 'I CEITTIFY THAT IN THE ORMAN'CE OF THE WORK FOR WHICH THIS PE IS ISSUED.I SHALL EMPLOY PERSONS SURJECT TO WORIGNAN'S COMPENSATION LAWS OF CALIFORNIA.' THE CANT MUST CA IN ADVANCE FOR ALL REQUIRED IMI a AT 1 1 4pJ423. COMPLETE DRAWING AT LOWER AREA PROVIDED. ' ^� r Blened x Title Dete f/ PLOT N IDreYv to Geotel 00e14 '!e I. NAME F STREETS OR ROADS NEAREST TO OR SOUNDING TI 11 to RrY. 4. LOCATION OF HOUSE SEWAGE OISPOSAL SYSTEM OR PIOPO9E0 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH RECTION. EXPANSION OF SEWAGE DFOMIAL SYSTEMS. 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADRIS OF ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRYVEWAY6,AND WAIXS. ON THE PROPERrY OR ADJOINIrM PROPERTY. ., _ . : I .... ..... .- i- ., .... ---- y� :. PAYMENT . - . FEB 2 2 1999 SA�k OAKlUIN COUNTY PustJC HE- ENVIRONMENTAL ii shr{v�C�y I=NVR}itJNR�lfN3�ALHErlLTM,{�11l351Ct37 3. t DEP TMENT USE ONLY Appllaellen AOvepled BY Gf Dole Areo _ GtoW Impeatten BY OetaPer�p In.adtlen BY Dote �rG� D—Mmilen IMpe tlon By Dot. cemmerx.: 1� SAG�.G�a � S 6.l5 wa.'`Ll.. lvEGL G'C�.SSsr.I GG wG T2� l ��Ci u !T vIc y `�7lGTA IG a/ad��1 G4 -TX'r�5, GE�rr�T�7� ^�F r � ACCOUNTING ONLY: MEW FACE PE CODER FEE INFO AMOUNT REMITTED CHECX AH RECEIVED a DATE PERMITISERVICE REQUEST NUMBER INVOICE I L4 (v a Rory 9 LZ �;+? C3vo --- � ,