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F" t)� APPLICATION FOR WELLIPUMP PERMIT /� ', <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.G.BOX 388,304 EAST WEBER AVENUE.STOCKTON.CA 95201388 <br /> (209) 466-3420 <br /> MOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In TrbRutal <br /> APPLICATION 18 WERE EY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CON67RLJCT AJIOIOR INSTALL THE WOFK DESCRIBED.THUS APPLICATION IS MACE IN COMPLIANCE MAT"SAN <br /> JOAOUIN COMMY D"LDPIArNI TrTLE,CHAPTER E 1 S.9 AND THE STANDARDS OF SAN JOAQUIN COUNTY RJRLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH 01-AfFION, <br /> JOB ADORE158IOR APNE. . <br /> CITY' PARCEL SFZF/PEPSI <br /> OWNER'S NAME_- - - ADDRESS / F PHONE <br /> CONTRACTOR_% ADDRESS LICS. PHONE S <br /> SUS CONTRACTOR ADDRE88 LICE PONE/ <br /> TYPE Of WELUrUMP; ❑NEW WELL _ ❑RER AC EMENT WELL ❑MONR GRIND WELL/ ❑OTHER_ <br /> ❑INSTALLATION ❑WELL SYSTEM PEPAm ❑CTCS9-CONNECT REFAM ❑ VAPOR EXTRACTION WELL 1 J <br /> O N-0RR..M M.F. OEM P1RJP SET^,FT. FIRST WATETI LEVEL O <br /> STYPE OF AIM% <br /> ❑OUT-0F SERVICE WELL ❑GEOPHYSICAL WELL S ❑ SOS sONNa S I` <br /> ❑DESTRUCTION: v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> 11 INDUSTRIAL ❑' OPEN BOTTOM DIA.OF WFIt EXCAVATION Y nGIA.OF CONDUCTOR CASINO O <br /> Q NE <br /> DOME910CM <br /> VATE l GRAVEL PACK/SIZE TYPE Of CASINOMTEFLAVC JLDM.OF WELL CASING 03 <br /> ❑PUSUCALUNICIPAL ❑DRIVEN DEPTH Of GROUT SEAL /1i8/ �f�t_ B101FICATK7N IF C <br /> ❑IRRIGATION/AG ❑OTH GROUT SEAL INSTALLED BY _ GROUT EIMNp <br /> ❑MONRONNO I GROUT SEAL PUMPED:OYr ❑N. CONCRETE PEDESTALSYOFjLuFLEly.'ON. e <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE RPF <br /> a <br /> PROPOSED CONSTRUCTIONAMLLTNO MUM13 MUD ROTARY _ AIR ROTARY AUGER_ CABLE OTHER <br /> I NEYEBY CEWAFY THAT 1 HAVE PREPARED THIS APPLICATION AND TI"AT THE V40M WILL BE DON!IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORONANCES,STATE LAWS.AND RULES AND <br /> REODUTIONS OF THE SAN JOAQLIRI COUNTY.HOME DImNER OR LICENSED AGENT'S SIONA7 URF CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PEMWMANCE OF THE WOIR FOR YYMCH <br /> THIS PERMIT 18 ISSUED,1 SHALL N07 EMPLOY PERSONS BUSJFCT TO WORKMAN'S COMPINSAITON LAWS OF CALIFORNIA.'CONTRACTORS HIRE"OR SLIBCONTFIACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTWY THAI m THE Pf RFOFVAANCE OF THE MARK FOR WHICH THIS PERMFT IB ISSUED.I SMALL EMPLOY PERSONS RUSACT TO WOR OWAN'S COMPSNIATION LAWS OF <br /> CALIFOIWIA." THE AFPICANT MUST CALL 24 MOLARS IN ADVANCE FOR ALL REQUIRED IIISPECTIDNS AT I2C*14484423.COMPLETE DINW%NO AT LOWER AREA PCVIDFO. <br /> al.—I X _ TIG. <br /> ROT PUN ID.—I.Saw}S-I. •ro <br /> 1.NAMES Of"FIFETS OR ICAO&NEAREST TO OR SOUNDING THE PIOPERrY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> Z.OUTLINE OF THE PROPERTY,GMNG DIMENSIONS ANO NORTH DIRECTION. EXPANSION Of SEWAGE DIAPOS,LL 8YETEMS- <br /> 2.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTMIG AND PROPOSED S.LOCATION OF WELLS VT 1+114 KADRFS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDIFIO COVERED AREAS SUCH A8 PATIOS,CUSVEWAYB,AND WALK9. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 14 ?996. <br /> ryFA, . . <br /> 0L7PARTMENr us!any F / ' <br /> APNluttr.Aea.PRed <br /> By G. r�,0�� Dat -7 I / 1p -w.ry f K <br /> GIR,A InWecnen BT� ,A 7 [.lJ� 1�RLmP inweatlRn By ---^^^---IIITTT���--- —O.t. <br /> D.,. 6 /J (J <br /> ACCO'JPITING ONLY: Prof FACE <br /> P'..coo" FEE INFO AAeOl11IT RBAITT FG CHECK ASH RECEIVED SY DATE PLIR.IT/SfiRVICE REQUEST NLIMSYL INVOICE <br /> ►� <br /> o QQSs , <br />