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a <br /> PLICATION ICOR WELUPUMP PERM <br /> SA AGIUIN COUNTY PUBLIC HEALTH SE .:ES <br /> ' ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> . NON REFUKDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUES! <br /> IComplatio M TripHants) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIGR INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE CHAPTER 9-1115 3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> JOB AODRESSIOR AW, _4�t Z LOWWT& LA.JE— CITY C+[.rL'= PARCEL SIZElAPNf <br /> OWNERS NAMEl`VLIL� P L-�r Cutv.PA,3Y ADDRESS C-��-riE�Prx.J�OZrL&!_ 106t!-- /� ['A PHONE v4'Es <br /> pa rG- 44 <br /> 33 Ea Sy 707-3-A4 <br /> CONTRACTOR La ouck.fA zab �l�a.J C- ADDRESS lZ-lG`y r A C-_'45,LUcs -7f4'TC]7 PHONE f. 4-bw <br /> SUB CONTRACTOR AbOnESS UGf PHONE f <br /> rvlu-'2 �nw^ <br /> TYPE OF WELLIPUMP, NEW WELL ❑ REPLACEMENT WELL MONITORING WELL f . OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLf J <br /> ❑Naw❑Reoelt N P DEPTH PUMP SET FT FIRST WATER LEVEL O <br /> {TYPE OF PUMP) <br /> ❑ OUT OF-SERVICE WELL ❑ OEOPHVSICAL WELL f ❑ SOIL BORING 8 <br /> ❑DESTRUCTION <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL Cl OPEN BOTTOM DIA OF WELL EXCAVATION 25 WC-%4 DIA OF CONDUCTOR CASINO D <br /> ❑ DOMESTICmitivATE ❑GRAVEL PACK/SIZE TYPE OF CABINGfSTEELIPVC SC-K 40 PDC— DIA OF WELL CASINO_.-2- 1 0 <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL -2-6 t=-r SPECIFICATION SC-4 4c7 P-JC- R <br /> ❑ IRRKIATIONIAG ❑OTHER GROUT SEAL INSTALLED BV -C1 w�\ GnOVT BRAND NAME CSF-.IY {2ia-i`ra-bI'4yr,- <br /> MONITORING GROUT SEAL PUMPED Yr. ❑No CONCRETE PEDESTAL BY DRILLER ❑Yea Cl No S <br /> APPROX bl"M LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOOED CONSTRUCTIOMMAILLING METHOD MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 NFelFRY CERTIFY THAT 1 14AVE PREPARED THIS APPLICATION AND THAT THE WOM WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES STATE LAWS AND RULES AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY HOME OWNER OR LICENSED AGENT S SIGNATURE CERTIFIES THE FOLLOWING '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF CALIFORNIA CONTRACTOR B HIRING OR BUB-CONTRACTING StONATURE CERTIFIES <br /> HE FOLLOWING *I CEntIFY THAT Irl THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED I SHALL EMPLOY PERSON9 SUBJECT TO WOtt"4AN 0 COMEN <br /> POATIOM LAWS OF <br /> WFORNIA' THE , UOT CALL 24 HOURG IN ADVANCE FOR ALL REGUMED INOPECTIONO AT 12001400-M423 COMPLETE DRAWING AT LOWER AREA PROVIDED <br /> � <br /> Signed X �irr Talo jygal4C T C LVL-cats beta JV Q <br /> PLOT PIAN IDrow to Seale)Baale 'to <br /> 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PSOPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2 OUTLINE OF THE PROPEF EXPANSION OF SEWAGE DISPOSAL BYSTEMS <br /> 3 DIMENSIONED OUrLINFS I� /� S LOCATION OF YYELL9 WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br /> STRUCTURES,INCLUDING / (// ON THE PROPERTY OR ADJOINING POOPERTY <br /> NL <br /> Application Aceepled Sy_ , Data Area <br /> Gragt Ir»peation Sy � 9� BY <br /> Dote <br /> D�tn,sllen Irweaetien Sy_ ✓(%Y�!�'�f l(J Date <br /> CemmerN• <br /> ACCOUNTING ONLY AIDE FACA <br /> PE CODED FEE INFO AMOUNT REMITTED CHECKRICASH RECEIVED BY TE pMfflT1SERVIC EOUEST NUMBER INVOICE <br /> Pub Health Sery -Envlro 173(1197) - - <br />