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APPLICATION FOR WELLIPUMP PERMIT <br /> —AN JOAQUIN COUNTY PUBLIC HEALTH SERVII, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOADUIN ST., STOCKTON, CA 95201-388 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tr'pliutd <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER R 1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> Joe ADDREB6/OR APN, 14 7 00 W . Schulte Rd uTY Tracy PARCEL BaEJAPN. <br /> OWNER'S NAME OWEnC Bra Ck WAy F.1ASG' ADDRESS RHONE I8' FA-R ALL <br /> CONTRACTOR ('1 L We-lI T ADDRESS 2024 E ChQrVAE' uce371 560 RHONEo467-7670 <br /> SUB CONTRACTORrr--HI ADDRESS (JCI RHONE <br /> TYPE OF WELL/PUMP: 11 NEW WELL ❑ REPLACEMENT WELL 4 b-J(MONITORING WELL P ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 J <br /> ❑New❑Rep." H.P. DEPTH RUMP SET_FT. FIRST WATER LEVEL O <br /> OYPE OF PUMP( <br /> ❑ OUTOFSERVICE WELL ❑ GEOPHYSICAL WELL I ❑ 601E BORINQ B <br /> ❑DESTRUCTIONS. <br /> INTENDED USE TYPE OF WELL CONSTREICTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL JJ❑--I OPEN BOTTOM �'/T DIA.OF WELL EXCAVATION 10 II DIA.OF CONDUCTOR CASING N n n a D <br /> Q <br /> ❑ DOMESTICMFLEVATE XBRAWL PACK/SIZE ✓ TYPE OF CASING/STEEL/PVC PVC, DIA,OF WEIR CASING q r h [in �EJ - O <br /> ❑ PUBLICMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL a D D r O X 1 5 0 SPECIFICATION R v <br /> VG <br /> C❑'1"IRRIGATION/AG ❑OTHER GROAT SEAL INSTALLED <br /> fE;;'B-1LY�� C I a T), GROUT <br /> BRAND N E O <br /> U.MONITORING GROUT SEAL PUMPED: O&WP ON. CONCRETE PEDESF YDRILIER©Yr [IN. S <br /> APPROX.DEPTH 1 Rn 1 LOCKING CHESTER W /STOVE RPE (/EpYI�cn91 <br /> PROPOSED CONSTRUCTION/pPoWNO METHOD: MUD ROTARY X X AIR NOTA�AUG cABIE OTHER ( ri�4 5"D c- <br /> DHie C't <br /> I HEMBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUI COUNTY. E OWNER OR LICENSED AGf Ni'6 SIGNATURE CEflTIFIE6 THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL N E OV PFRSO f/8A)WE T TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES� <br /> THE FOLLOWING: 1 CE HEV T HE IIFO AN E F HE WOW FOR WHICH THIS PERMIT 16 ISSUED, SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of <br /> CALIFORNIA.' THE CANT BT LL E FOR ALL REQUIRED INSPECTION{AT 130e14N3M20. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> slen.e x /ffTill. VP Clark Well D.t.31 Mar 95 n <br /> PUN ID,.w tP 6C.1.1 Sul. <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUFUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> v (rC- R v <br /> She c Ai <br /> i <br /> r -- <br /> � <br /> ///�y�/� <br /> DEPARTMENT USE ONLY <br /> AppLullen Acc«tetl By_ / E 1 y .3 n I <br /> Dae <br /> c,em INIRKu.n ev IM '1'1A¢o_.�S one z' S5-. <br /> wmp In.v«{ren By <br /> IJn. <br /> D tr Tion Imwtlon By <br /> D.le <br /> JFIFcomments <br /> ACCOUNTINO ONLY: AIDA PAC. <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMITISERVICE REOU"T NURSER INVOICE <br /> 351P `6 3 lZA AL}.3 lib 5(0 <br />