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� APPLICATION FOR WELL/PUMP PE PAYMENT JOAQUIN COUNTY PUBLIC HEALTH VVICES r%P'^(r`?«Awn ENVIRONMENTAL HEALTH DIVISION " 1. - , 304 EAST WEBER AVENUE, STOCKTON, CA 95202 OCT 16199® (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN joAt3U'N EUUNPY R MUC H€AUN€€RVjdt§ (Complete In Triplicate) ENV'k0NMWNtAL H€ALtH diff iN APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COURry FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED,THM APPLICATION 18 MADE IN COMPLIANCE WRIT BAN JOAQUIN COUNTY DEVELOPME RIE,CHAPTER B-1116,.131 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC 1HEALTH BERVICEB,ENVIRONMENTAL �HEALTH .DMBION. `h JOB AODRESM ,AP1N•I- 1 -I-,L�DIYjTR(f� Ave CITY 121p -A CA `755&(P PARCEL SIZUAAPPNI 259-3;DIO OWNER'SNAME 0(114le VSAS /�-ry ADDRESS Bfn &I. BrarIJ Rl vd 6[endnalP«ONl/E�I 918 549. 5948 CONTRACTOR Fluor �1l e I C71 I �C ADDRESS 75{7y) /r�na d Ll.- sk/` b 'LICeS 170 /0 Qlf�9 ( [/y® SUBCONTRACTOR C�/'c G �I/I(/�� ADORE68 .JI.! AF {L�t' C'CYC�f LICI T01�(vJ (QH I�I�'JO�/L� TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL e �OTPIER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSQONNECT REPAIR ❑ VAPOR EXTRACTION WELL I O 11 J DUPE OF PUMP) 11 N.❑RaP.II H.P. DEPTH RUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-8ERVKU WELL ❑ GEOPHYSICAL WELL! ❑ SOIL BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION'SPECIFICATIONS I ��///��, A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 11 �Y� D DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPEOF CASINOISTEELIPVC DIA.OF WELL CASINO ❑ PUBLICIMUNICIPAL 11 DRIVEN DEPTH OF GROW SEAL /� Z-� SPECIFICATION ,p / R ❑ IRRIGANON/AG ❑OTHER GROW SEAL INSTALLED BY_G��tr BMW BRAND NAME all' GO -r`J"P 'OU F ❑ MONITORING GROUT 6EAL PUMPEO�Y. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yr [IN. S APPROX.OFPTH I , LOCKING CHESTER BOX/RTOVE REE 5 PROPOSED CONSTRUCTIOWDRLIINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'8 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR NMICH THIS PERMIT IB ISSUED,18NALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'8 HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CIWIFY THAT 1 HCPERFORMANCE OF THE WORK FOR WHICH 11-1I8 PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T(IE)APPIJCA T CALL 24 �A ADVANCE FOR ALL REOMM INSPECTION/AT IMI 46/.1412. COMPLETE DRAWING AT LOWER AMA POVIDED. rw 81PX TIK. PLOT PLAN P.Ia SA,0.l Beaty 'R / I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE P OMP TY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENBIONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED K. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATOB,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. S d1 rAc t1 SIVE' �( P 1�I . .. .7_. _ ..3..... .. ...:. ......L.. J_....y DEPARTMENT USE ONLY AP,Hwl.n A...W or �ILL.z-c'-G� (� Dal._ %U —161 '- l� Ara. O)'S(O GreU I.P.H.By D.I. Po P InowtIon By D.I. O D.Ia De.bwtlen Imnaetlen ev uA - R�CXr++h�i Et" �y ACCOUNTING ONLY: AIDS FAC# PE CODES FEE INTO AMOUNT REMITTED HEC /CASH RECEIVED BY DATE IT ERVICF REQUEST NUMBER INVOICE !(%/ !!oo iJ /!� o/733d Pub.Health Serv.-Enviro.173(1/97)