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_ i _, , <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FRDM DATE ISSUED <br /> (complete Is TrIpRemle) <br /> APPLICATION IS HtAf BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT 70 CONSTRUCT ANOMPI INSTALL THE WORK DESCRIBED.71118 APPLICATION IR MADE IN COMPLIANCE WRIT SAN <br /> 'JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 0-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AGGRESSION APINP _/ �N�1� / �LL��-�2�/�1-�L,`.�'✓� /LCI Cm 0—eLc PARCEL SIZEIAPN/ 1/ 1� <br /> OWNER'S NAMEY� �7'—•`'I�f � I"'�—/�`��^�' , ADDRESS /��// .7 RHONE I�C`+ `O[al 7 J` <br /> —CONTRACTOR ��C G6� /� t�J ADDRESS fg T lO Q 1 C.�, '.ti EJC,_& ))32? PHONE <br /> RUB CONTRACTOR ADDRESS LIC. PHONE/ <br /> TYPE OF WEUJPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL/ ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL F J <br /> ❑N—11 R.PNr N.P. -:z DEPTH PUMP SETFT. FIRST WATER LEVEL /•I�/ O <br /> IT YPE OF PUMPI <br /> ❑OVT-0E-SERVICE WELL ❑GEOPHYSICAL WELL/ ❑ SOIL SONNO S <br /> ❑oerr11R12T/ON:-. 1 �� <br /> —INTENDED USE TYPE OF WELL CONSTRIUCTION SPECIFICATIONS A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO G <br /> ❑DOMEBTK:/MVATE ❑GRAVEL PACK/SIZE TYPE OF CASIMISTEELMVC DIA.OF WELL CASINO D <br /> D❑1 PUBUCIMUFMtPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> 21-1-MUGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> -0 MONITORING GROUT SEAL PUMPED:❑Y.. [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr CIN. S <br /> APPROX.DKI'TH LOCKING CHESTER SOII/SfOVE PIPE S <br /> PROPOSED CONSTRUCTIONIDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HERESY CERTIFY THAT I PIAVE PREPARED THIN APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> RfOULATIONS OF THE SAN JOAOVN COUNTY.HOME OWNER OR LICENSED AOEM'S SIGNATURE CERTSIEB THE FOLLOWNO:'I CERTIFY THAT IN THE PREOR MANCE OF THE WORK FOR WINCH <br /> 71119 PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SU9COMRACTN MONATURE CEMIHEN <br /> THE FOLLOWING: •1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIN PERMIT RI ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WOIIIVAAN'S COMPENSATION LAW.OF <br /> CALIFORNI 1�- TINE APPUCANT M,VST CALL 14 HOU IN ADVANCE FOR ALLREOUS IAP INSP�E/CJTNIN9 AT 1109).p-f.11.COMPLETE DRAWING AT LOWER AREA PWPVIDED. <br /> Swr,.e K /L /A- /y 4T/- Y Al ems- D.1. zo <br /> PLOT PLAN 111,. 11 9er.1 Be.l. le <br /> I.NAMES OF STREETS OR ROADS NEAREST TO ON BOUNDNO THE PROPERTY. E. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PRDPfRrY,01VNIO DIMENSIONS AND NORTH DIRECTION. EXPANSON OF SEWAGE DISPOSAL SYSTEMS. E� <br /> U.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPENfY OR AOJ01NN0 PROPERTY. <br /> AUG 11 1998 <br /> 1U[3uc HE n 'i <br /> iLlaLTTI <br /> c _ CNVInONMENTAI HFAITH pIVI�in. <br /> DEPARTMENT USE ONLY <br /> APPIi—P—Ar.NP1.d 9Y D.1. N.. <br /> orwl IrwPmlMn Br on. Pr,r.re wP.,tl.n Br <br /> 1rlrrclNn IrwP.elbO BY D.1. <br /> ACCOUNTING ONLY: ANO/ FAC. <br /> PE CODES FEE INFO AMOUNT RFZAITT ED HE .K ASH RECEIVED BY DATE PEEIBTIEERVICE REQUEST NUMBER INVOICE <br /> 0 <br />