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I&PLICATION FOR WELL�PUMP PERMI0 <br /> X,CIA ogt',,P,,,: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Yn e Lea..-- VA 2 Z 1K:)2 <br /> 5 S. Ga -»� Sot- ENVIRONMENTAL HEALTH DIVISION <br /> S `� y �� 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> 95 ZOZ (209) 468.3420 p ;CIANCE <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED(Complete In TdpRcatel <br /> APRJCATION IS HERE eY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WOW DESCRIBED.THIS APPLICATION ITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1113.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTALJOB ADDAESBDR AM# 7� f $O o2 I.J. (-J a�ae.� 11 e. . CITY S�C�C�rJ PAnc£L 0-0) <br /> D 'ADO C0iZfC, AT �iDGE 43S <br /> OWNER'S NAME eLTA 6TATe LJPIy PA(L-TNe/LS{!IQ AGOPESB PHONFf n <br /> CONTRACTOR If-C I'd AJ ADDRESS IYO° S_ '664,z 1`^UCE O M.N. <br /> . nT YS/S <br /> e,.LSV LTA N'T 3D 3B PrHTOBNE/ <br /> ten- C LA 4�N ADDRESS to 92n K6 LL CT(L- Pk'Ti r LJ ASAA al `{Z--71 <br /> —� ONE <br /> 9Zs <br /> -80 <br /> TYPE OF WELIJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL i ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-0ONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑New❑ <br /> RYPE OF PUMP) H .Ir M.P. OEM"PUMP SET—FT. EVFIRST WATER LEL O <br /> II <br /> (/I / ❑ OUTO0FyB ICES WELL ❑ OECMYSICAL WA.EItU.i -SO1R SOMM / .L g <br /> []DESTRUCTION: �I - �" (JQ'U.�wn o2-T 1� OL��+ SILLA UVCM- "IL�2�0� MY+�T I�Y2C�2L 111 �A-PM✓N^K. 4tO.` <br /> 1 LENOED U E TYPE Of WELL CONSTRUCTION EP£CIFICATIONS A <br /> 11 INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTICIPRIVATE 13 GRAVEL PACXISDE TYPE OF CASINGISTEEL/PVC DIA.OF WELL CASINO p <br /> ❑ PIBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A <br /> ❑ MAIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONNORINO GROUT SEAL PUMPED: ❑Ys [IN. CONCRETE PEDESTAL BY DRILLER:❑Y- ❑N. S <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE E <br /> PROPOSED CONaiRUOTmNIONWNO METHOD: MUD VOTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPIJCATMN AND THAT THE WOR(WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES ARE <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONA SUBJECTTO WORKMAN'{COMPENEATIOM"WOOF CALIFORNIA' CONTRACTOR'S HIRING OR BUSCOWMCTIM MNATURF CEIDIFMS <br /> THE FOLLOWmG: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOM FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY MASONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THIS APPUC NT UST CALL N HOURS IM ADVANCE FOR ALL REOUAEO INSPECTIONS ATy1]20e1 44111414". COMPLETE DRAWING AT LOWER AREA PROVIDED, <br /> aroma x TIB._ ( /�--5�T 00. Z� C 2— <br /> Lf <br /> LOT RAM iprnv!R Serol <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR 80 MNG THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE OISFOSAL SYSTEM OR MOPOSED <br /> I. OUTLINE OF THE PROPMTTY-GING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> O. DIMENSIONED OUTUNfa ANO LOCATION OF ALL"RITIM AND MOMSEO - S. LOCATION OF WELLS WRHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAVS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ?� <br /> .;..�".;,ex;>�.}.��a-�eF>a..+ <br /> _ 5 ..... <br /> PaT; 7L 1 . . ..` o .....: . <br /> DEPARTMENT We ONLY <br /> APPe.rbn Ammred BY MN Arr <br /> Orau1 Impembn DY Oaa AimP Impmtlan BY Daa <br /> D+,meLbn Impevfbn By �,� <br /> C.mmwR.: <br /> ACCOUNTING ONLY: AID, FAG <br /> PE CODEX FEE INFO AMOUNT REMITTED CNECXI.'CAEH RECEIVED 9Y BATF PBOAITIeFIMC£R QUEST NLMB91 INVOICE <br /> f <br /> Pub.Health SEN.-Enviro.173(1/97) <br />