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t pci <br />IC a tp <br />\a% <br />... <br />...•.... <br />PAYMENT <br />ROT:E:V"1. <br />-MAR 11 4996 , . <br />SAN jaAC(LliNC OL. , <br />PUBLIC HEALTH SERVICES <br />ENVIRdIUMNTAL J.-EAU-0 <br />APPLICATION FOR WELLMUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />PO. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209} 413B-3420 <br />NOMREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete In Trip Rate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDOII INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9 -1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR ARNE ‘"\-- . <br />C <br />C:1\.13%, Vt.2•Q•\L• PAFAL SMEMPTIO <br />OWNER'S NAME 7 ATORESS S PHONE //C;Cia 0 <br />CONTRACTOR L\\‘••••VC...\) ROOPERS LLCE ,...,,\AL,As*543°A <br />EXIS CONTRACTOR ADORES8 LIC• PHONE <br />TYPE OF WEIJJKIMP: 0 NEW WELL <br />Sk-1\ <br /> sg INSTALLATION <br />ETYPE OF PUMP) <br /> 71,Nwn 0 Repair <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />0 OUT-OF-SERVICE WELL <br />0 MONITORIN3 WELL II <br /> LI OTHER <br />0 VAPOR EXTRACTION WELL I • <br />FIRST WATER LEVEL t. o <br />0 GEOPHYSICAL WELL 5 0 BOIL BORING <br />0 CROSS-CONNECT REPAIR <br />DEPTH PUMP SETN3 FT. 0 <br />s <br />0 DESTRUCTION' <br />INTENDED USE <br />sg <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />0 PUBUC./MUNICIPAL <br />0 IFIRGATION/A0 <br />0 MONITORING <br />APPROX. DEPTH <br />TYPE OF WEIL <br />t(OPEN BOTTOM <br />GRAVEL PACK/BITE <br />0 DRIVEN <br />0 OTHER <br />PROPOSED CONSTRUCTIONTDRILLJNO METHOD MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />GROUT SEAL PUMPED DV.. ON., CONCRETE PEDESTAL BY MUTER. 0 Yoe ON. <br />LOCKING CHESTER SOS/STOVE PIPE <br /> AIR NOTARY AUGER CAERE OTHER <br />DIA, OF CONDUCTOR CASING <br />DIA. OF WELL CASING <br />SPECIFICATION <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AN/3 THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 10A0U114 COUNTY ORDINANCES, STATE LAWS. AND RULES ANOt <br />REGUTATX)N13 OF THE BAN JOAOUIN COUNTY. NOME OWNER OR LICENSED NT AGE'S SIGNATURE CERTINES THE FOLLOWING: •I CERTIFY THAT IN THE PERFOWAANCE OF THE WORK FOR WMC <br />THIS PERMIT III ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S Hramta OR MAI CONTRACTING SIGNATUPE CEIRTOtt. <br />THE FOLLOWING: • 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISEDED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN .. COMPENSATION LAWS OF <br />ED-111 \ CAUFORNIA.• THE APPUCAIIT MUST CALL 24 HOURS IN ADVANCE MO ALL RECESS memo* AT I2011 484-2422 , COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />9Ipmel X.1\-.., ............_N.-...., ..C.C....... Till* ‘'''•)Z-•% \t••-,—\(..._,,Q.----...._. Dote .• <br />- <br />PLOT PLAN 10low to Scale) 64410 • lo <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. <br />OLTTLLNE OF THE PROPERTY. GIVING DIMEIHNONS AM) NORTH DIRECTION. <br />DIMENSIONED OUTLINES AM) LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS. AND WALKS, <br /> <br />4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSER <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PRI2PER1Y. <br />Applleatkm A...opted By <br />Grout IropectIon By <br /> <br />DEPARTMENT USE ONLY <br /> <br />Run, Inapoctlon By <br /> <br />InopootIon By <br />Commonly <br /> <br />ACCOUNTING ONLY: AIDS FACE <br />I <br />PE CODES <br />-.e <br />ElI2 AMOUNT REMITTED HEC /CASH RECEIVED BY DATE <br />— <br />FERMITMERVICI MOUT NUMBER INVOICE <br />i•il * 0' 1110 <br />e <br />1 4 sr <br />/ <br />A i <br />I- , 0 (L.! r 1 A L,.' <br />SRono q131-40