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APPLICATION FOR WELLIPUMP PERMIT" <br /> SAN JOAO COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> \N 0--\*00 P,O, BOX 3K 304 EAST WEBER AVENUE, STOCKTON, CA 95201 <br /> ` (209) 4683420 W; L L <br /> 0 UNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED 1000 /� <br /> ICgmPb1E In TrIBIkE1EI /� <br /> ` APPLICATION IP NFRE SY MADE TO THE SAN JOAQUIN COV OR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IP MADE IN COMPI�R�A,F�'. <br /> JOAQUIN COUNFV DEVELOPMENT TOLE,CHAPTER R-1115.3 AND TIIE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> UBLIICHEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 1 A✓ !� <br /> JOB ADOWRSIOR AM# 093� -yo �— D CITE S�1 f/(/F',7o L/\ PARCEL SIZE/APNF IZ V_ <br /> OWNEq'S NAME RaM W i ICV <br /> ADDRESS L•R,L�� (+ PIONFN <br /> CONTRACTOR _IC�Lrl"�lG ADiNREPBZ F� JV S7`. <br /> y - HC/ PNONF F <br /> PVB COMRACTOP S f}{Q• ��yF u wt ADDRESS ICI 5 1 226$PHONE F <br /> TYPE OF WELL/PUMP, ❑ HEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CM99 CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F ,l <br /> RVPE OF PUMP! <br /> ❑Nee❑RseNr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL a � <br /> � � 11pp <br /> ❑ OUT or SERVICE WELL (• L❑ OEOPIYSICAL WELL 0 W SOIL ROBINS 3 LS 5p I R <br /> ❑OFBTRUCiION��\ 1 I ���I ~/�)��b��—�ER l.I w (AA. 1L V <br /> IN _.TENDED USE 7 <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS ♦ II •` <br /> El INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION L/D DIA.OF CONDUCTOR CASINO <br /> ❑ OOMESTMq VATS ❑GRAVEL PACK/SIZE TVR OF CAPINGISTFEUPVC DIA.OF WELL CASINO <br /> ❑ RURLICmUNICIPAL ❑OBIVEN DERV OF GROUT SEAL SPECIFICATION <br /> ❑ IRRIOATIONIAO ❑OTHER GROUT SEAL INSTALLED BYGROUT BRAND NAME P <br /> RI <br /> ❑ MONITONG GROUT REAL PVMCFD: 11 ❑Yr Ne CONCRETE PEDESTAL BY DRILLER:❑Yr 01, <br /> APPROX.DER" LOCKING CNESTEB BO%/STOVE PPF , f <br /> ` PNOPO@ED COMSTIUC110NIDRIWNO METHOD: MILD ROTARY AIR ROTARY AMER CABLE OTHER <br /> -- <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WRIT.BE DONE IN ACCORDANCE WITH SAN"AWIN COUNTY ORDINANCES,STATE LAWS,ANO mi—mg AHO <br /> REOULATMNS OF THE RAN JOAQUIN COUNTY. HOME OW4NR OR LICENSED AOENT'B SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PEWORMANCE OF THE WORK FOR WIIICN <br /> TIS9 PERMIT IS ISSUED,I SIONLL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFNSATON UW S OF CALIFORNIA.- COW RACTOR'8 HIM"OR OUR CONTRACTING SIGNATURE C,LIrtIF%% <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOM WHICH THIS PERMrt IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFNRATION LAW$OF <br /> CALIFORNIA.- THE AppUC NTglT CyALL�ZA HOUGS IN ADVANCE FOR ALL MOWED INNSO'IMIO�NS AT IZeBT AYJMXE. COMPETE DRAWING AT LOWER AREA PROVIDED. <br /> BIPrw X�O---�J�1. �aLQ-,I, TRI. JTZLcr't" Eln OI Iy1 G<V 'Z l3'4�O <br /> DeU <br /> r POT PAN MI.M Seelel Seel. 'Rs <br /> 1. NAME@ OF STRERS OR ROAOR NEAREST TO OR BOUNDING THE PROPERrY. A. LOCATION OF(OUSE SEWAGE DISPOSAL SYSTEM AA POPOSFO <br /> i. OUTLINE OF THE PIDPERrY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE WAG E01 MRAL SY <br /> G. DIMENSIONED OW LINFS AND LOCATION OF ALL EXISTING AND PROPOSED E. LOCATON OF WELLS E DISPTHIN MRATS T ONE HUNDRED PRY fT. <br /> B. <br /> STRUCTURES,INCLUDING COVERED AREAS SVC"AS PATOe,DRIVEWAYS,AIIp WALKS. ON THE PROPERTY OR ADJOINING PmDPERrY'. <br /> EXPIRED <br /> S <br /> Sf�e. TN <br /> AUG t 9 `1`3 'r, - 11 <br /> EPL iL SR 'Sri <br /> DEPARTMENT USE ONLY // <br /> ApNHNMn AFeeplvA BT 0.4. Nr /[_ <br /> GOuI Iwpa$m,By DNe P—peplln,pmtlen By <br /> DBNnHIbR 1-1-11x•BY r,y p ONe <br /> Cemmaar __ <br /> ACCOUNTING ONLY: AID$ FAC/ <br /> pE CODES FEE INFO AMOUNT REMITTED CHECK/!CASH RECEIVED BY DATE FEOMIT/SERVICE MOLEST NUMBER INVOICE <br /> L c 1U Jam. cN T 3 <br /> Pub.Health Sew -Elrviro.173(3/96) <br />