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' PLICATION FOR WELUPUMP PESMI0 m , L,-o,,, VH zZ Ips <br /> �oCOA Qg-rA/�-ea SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> .25 S. Cevw anc4 ENVIRONMENTAL HEALTH DIVISION <br /> CA 95 Zoz 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> RON-REEUNDARLE PERMIT EXPIRES I YEAR "077 DATE ISSUED )COMMCE <br /> late <br /> al <br /> APPLICATON IS HERE BY MADE TO THE SAN JOAOUM COUNTY FOR A PERMrr TO CONSPRI ANOMM INSTALL THE WOIK DESCRIBED.THIS APPLICATION IS MATH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHApPTER 9.1115.3 ANO THESTANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICER,ENVBONMENTAL HEALJOS ADDREBBroR APNI 7?0 � ll I)�- � � ��+.__ (111 . CT' � I`J C9-�" oPARCEL BrzHAU _0 <br /> ER'S NAME1� j-W the c.TR GRTe 4j&• l flArcrNaas ADDRESS-2 D00 L2'lz]QIQii' FGA-,-J 1 <br /> CONTRACTOR CReGG DRIL-L)AJG z�—�{ /UZs 1 <br /> �Dn1sGLri+A/-T ADDREBB95o JJUeStSt. MIO TI (oS/Fo{oq 113313--.57oo <br /> °U°�BOq— G�"��UN ADDRESS `920 ott Ci'P_. QI;l'1 XJcs /LRJAAn'ONE/ ZL•ZL00 <br /> TYPE OF WELLIFUMP• ❑ NEW WELL ❑ ME Ewm-r WELL ❑ MONITORING WELL B ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> RYPE OF PUMP) <br /> ❑N.❑R.oW H.P. DEPTH RUMP SET_FT. FIRST WATER LEVEL G <br /> ❑INTFN97- <br /> O z)USE1 V- 0 <br /> IOUT-01`- VE WSELP.A ❑1 GIEOPYSICAL WELL F Solt <br /> BOILBOPoNO <br /> DESTRHCTIOA ce:;z A/ <br /> }/. <br /> �LvWo <br /> TYPOF AL.�PJ <br /> B <br /> WELL 1, OONSTRUCTION rSPECIPCAT1ONe <br /> I� ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO A <br /> D <br /> DOMESTICNPoVATE 11 GRAM pACK18DE TYPE OF CABINOIBTEEINVC DIA.OF WELL CASING D <br /> ❑ mBmmUNICRAL ❑DPoVEN DEPTH OF GI SEAL SPECIFICATION <br /> R <br /> ❑ IRRIGAHONIAG ❑OTHER GROUT HEAL INSTALLED BY GROUT BRAND NAME <br /> 11 E <br /> MONITORING 01gVT SEAL PUMPED! ❑Ys [IN. CONCRETE PEDESTAL BV DRILLER:❑YM ❑Na S <br /> APPROX.DEPTH LOCXING CHESTER BOIUHTOVE RPE 3 <br /> RIOPOSED CONSTRUCTIONIOPoWNO METHOD: MUD ROTARYAIR ROTARY AUGER CABLE OTHER <br /> 1 WE Sy CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WOM WILL BE DONE N ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FDR WHICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORSMAN'S COMPENSATION LAWS OF CAUFO MIA.• CONTRACTOWS HIRING on BUBLONTRACTINIG SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFOPEIANCE OF THE WORK FOR WHICH THIS PEWIT 18 ISSUED.i SHALL EMPLOY PERSONS SUBJECT TO WORgMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT YAUPT CALL <br /> 24 Ib URS IN ADVANCE FOR ALL ILEOIARED IN;FECT1(01N8 AT CMH 4004E33. COMPETE DRAWING AT LOWER AREA PRO OED. <br /> BIKrod X 4=�/-/`� Tln. 1— <br /> oT PLAN O,..v 1.%e .H&.1. •ro <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOU NG THE PROPERrv. �. LOCATION OF HOVeE SEWAGE D18POSAL SYSTEM OR PPOIOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS NORTH DIRECTION. EXPANSION OF SEWAGE DURN)SAL SYSTEMS. <br /> 3. DIMENSIONED OUfUNES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUB OF ONE HUNDRED FIFTY FT. <br /> STRyU�C�TURI INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WALX3. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> s � <br /> ARTMENT USE ONLY <br /> Apply.Lbn Aa tW Ey DK. ATr <br /> O.ew Irwpm.bn BI Oaa <br /> PUmp InromBen By <br /> D.L. <br /> Dmm.,nen In.emnen ar <br /> D.L. <br /> cemn.mL.� <br /> ACCOUNTING ONLY: AID/ FACT <br /> pE coo" FEE INFO AMOUNT REMIT l IT C M0XfMASSH RECENED BY DATE PERMIT/SERVICE RE VEST NIUMBER INVOICE <br /> o © d <br /> Pub.Heaflh Se".-Emiro.173(1197) <br />