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APPLIRATION FOR WELLIPUMP PERMIT \ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> \ ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388,304 EAST WEBER AVENUE, STOCKTON. CA 95201388 <br /> 1 (209) 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICGmpMP In Triplicate) <br /> APPLICATION IB HERE M MADE TO THE BAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN <br /> JOAOUIN COUNTY DEVELOPMENT TRUE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY <br /> 'I IRU.CC HEALTH SERVICES•ENVIRONMENTAL HEALTH DMBION. <br /> JOR ADDRESSMR APHIL 42,,//4111 E, FiPf—ft d- Srlr et CIFTI1Y J TOCk p—F Fp�� PARCEL BIZEIAPNI <br /> OWNER'S NAME rs4it 0; ADDRESS -Q, BOX 1$o SO F Al/ 1%� VIQ�. (' PHONE#SID-335- 2? <br /> CONTRACTOR F.SWi"SITIAc_ ADDRESS .270 Perkl'MS .CM//l•YBUC# MGM E <br /> BU0t�sn'93S'48Sy <br /> B Co..,.,Co..,O" G•Yr� Dri IIfA ADOnEee 950 aYt%rto7_ uc#yss�cs "MeN.Y JI3-SSM <br /> TYPE OF MIJJPUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑ <br /> N—11 F—.1, H.P. DEPTH PIMP SET_Ff. FIRST WATER LEVELp 1p�C p_ O <br /> PE <br /> RYOF RIMPI ❑ OUT-0F SERVICE WELL ❑ GEORIY6ICAL WELL# BOIL Boom b8�l 5 8 9 <br /> ❑DESTRUCTION' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> ❑ DOMFSTIC"IVATE ❑OMVEL PACKI9RE TYYF OF CASofO19T1AJPVC DIA.OF WELL CASINO O <br /> ❑ P(GIUCMVNICIPAL ❑DRIVEN DEPFH OF GROUT SEAL BT4CUICATION B <br /> ❑IUL IHRIGATIONIAG 11 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> IAl MONITORING GROUT SEAL PUMPED: ❑Y. LIN. CONCRETE PEDESTAL BY DRILLER:❑Yr Li N. 5 <br /> APPROX.DEPTH 30 —40 LOCKING CHESTER BO%iBTOVE RPf S <br /> PROPOSED CONSTRUCTIONI LLNO METHOD: MUD RDTARY AIR ROTARY AUGER X CABLE OTHER <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE GONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES ANO <br /> REOUTATION9 OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THm PEnMR IS ISSUEO.1911A1 L NOT EMM OY PERSONS SUBJECT TO WORKMAN'S COMPENSATON LAWS OF CALIFORMA.- CONTRACTOR'B MMM OR BUB-CONTMCTING SIONATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 MALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT WOT CALL24 IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1 641466, }3, COMPLETE DRAINING AT LOWER AREA PROVIDED.SI,„S% C �,,�� TRI. <br /> �— <br /> MOT PLAN to,.m SeJel BetlA •IS <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PR)PERLY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYBFEM OR PRI PcHRn <br /> 2. OUTLINE OF THE PROPRLY.OMNG OIMFNSIONR AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLNFR AND LOCATION OF ALL FXIRTIN I AND PV)FO6ED B. LOCATION OF WFLL9 WITHIN RADIUS OF ONE HUNDRED FIFTY fT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON TIIE PROPERTY OR ADJOINING RIUPERTY. <br /> 7Zta�o �a- <br /> DEPARTMENT USE ONLY a <br /> APMIeKbn A.1-1 BY DHF /O �� / / NFP.. <br /> nreul HnPs,bn BY DFIs qmn ImeaeHnn Rr OKa <br /> DwbwlbR S+nallan By P DHa <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT"EMITTED CHECKOMASH RECEIVED BY DATE PBIMITISERVICE MODEST NUMBER INVOICE <br /> SB f ,o <br /> Pub.Health Serv.-Enviro.173(3/96) <br />