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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIONC� <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Cal"pbt[ IN TrlpRe[1e1 <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.TARS APPLICATION IB MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 ANDTHESTANDARDS_OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> .108 ADOREBS/OR APNI��- I 10 S I EZS S-IV (160; N AVE CF-Y S�[�C../•�yuN ,},�� /� �P/A/RCCEEL 812F/APNI z r IV <br /> OWNER'S NAME 1ILL 13�1 V 6r ADDREBR�'O8 1• D I/I-ri(A I��U-� r"' ��� / <br /> CONTRACTOa�IE((� D./t�JOEQ-Sd� SOC. INC. ., !-q ' / <br /> i �I� ADIMERB Z Z IJ. /WJ(0�l F I.D�I IICIIOtIJ !DO 4 i`FIONE• 103 'T-3 I <br /> RUB CONTRACTOR ADORE Be UC/ PHONE F <br /> _TYPE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROPS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> (TYPE OF PUMP) ❑N—11Reo.4 H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> � I <br /> ❑ OVT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL f ` ROIL BORING < ) - ro e <br /> ❑OESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> INWBTRAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I DIA.OF CONDUCTOR CASINO O <br /> ❑ D0ME8TIC/PRVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO D <br /> ❑ PUBLIC/MUMCMAL ��❑yy DRIVEN ! DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRLIOATION/AG yd OTHER L-^�� N� ` GROUT REAL INSTALLED BY OROVi BRAND NAME SOIL.. <br /> ❑ MONITORING / GROUT SEAL PUMPED: ❑Y- ❑Ne CONCRETE PEDESTAL BV DRILLER:❑Yw ❑Ne S <br /> APPROX.DEITH /62 LOCKING CHESTER Box/STOVE PIPE S <br /> PROPOSED CONSTAUCTIONMRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br /> 1 FIMBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCOFIOANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOA IN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> T/IS PERMIT IB ISSyA1"—MUWT <br /> T EMPLOY PERSONS SUBJECT TO WORKMAN'[COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR RUBCONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWINO: HAT IN TI/E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN*[COMPENSATION LAWS OF <br /> CALWONMA.' UST C II tLS IN ADVANC[FOR ALL REOUMEO INt►FC TIOT/ONS Ai 120[1 A«-H2f. COMI'1.ETE DRAWING AT LOWER AREA PROVIDED <br /> Slvr d X Tltl. - <br /> / <br /> Dae <br /> PLOT PLAN M—to 94.1.1 Roel. 'to <br /> 1. NAMES O/IWFES PROPERTY.OR ROADS NEAREST TO OR BOUNDING THE PPERTY. S- LOCATION OF HOUSE SEWAGE OIBPOSAL SYSTEM OR PROPOSED2. OUTLINEROPERTY,OrVIINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AMC PROPOSED S. LOCATION OF WELLS WITHIN RAOI/S OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLVOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR Ao"NINO PROPERTY. <br /> i <br /> LU <br /> N <br /> 3 � <br /> N <br /> DU <br /> 710w <br /> . ` a. Jr <br /> JAOUiIv l .c:M[., <br /> tNORCJTv1 L ri aLTH <br /> cb <br /> „-n !kEA <br /> 1 <br /> ARTMENT USE ONLY <br /> nvvllo.tlen Aaeepl.A BY L/vl/( t Lf,\,/L.�U V0."•S-14J_1,C\) <br /> Grout I-voetlen By Oae N1 v Irnvevtlen By Dae <br /> 0ee1n1e0en I-roc lon By D.I. <br /> Ce�nmwN.: f:UP51 <br /> `J s <br /> ACCOUNTING ONLY: AID/ FACT <br /> pE CODE[ FEE INFO AMOUNT REMITTED CHEC /CASH RECE EO BY DATE PERMITISEAVICE REQUEST NUMBER INVOICE <br /> Pub Health Serv.-Enviro. 173(1/97) <br />