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� APPLICATION FOR PUBLICWELLIpUMpA PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERYII� <br /> P.O. BOX 988, V9 FEASTWEBERA/ENUE,LTHISTOCKT'ON. CA 95201 <br /> VISION <br /> SEP � � 1996 me <br /> (209( 468-3420 <br /> .... N�M•AEFUIYpAB[E AERINIT EXPIRES YEAR FROM QATE ISSUEp <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT IA DF/OR INSTAL!THE WORK DESCRIBED.THIS APPOCAT10N 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CRAFTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN/ ZO ak S4 4 / <br /> /� L� core L o D r <br /> OWNER'S NAME �/ /nom PARCEL SIZF/APNI <br /> a LNC �T'S�.ADbREB1 <br /> CONTRAC70R /�j L/'l.y'Q �`y G PHONE! <br /> ADDRESS a2S $ 11..N �, 7117 <br /> lC <br /> SUB CONTRACTOR �76 ,�PHONE f <br /> ADDRESS ��s-�8 SO <br /> �. fv 4 <br /> SO ll{oWC J i6� <br /> HE <br /> p{iG ��tl r s <br /> TYPE OF�L/PUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL• <br /> 13 INSTALLATION El WELL SYSTEM REPAIR El OTHER <br /> ❑ CROUB-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> © J <br /> Repair H.p, DEPTH PUMP SET FT, <br /> (TYPE OF PUMPI Now FIRST WATER LEVEL O <br /> ❑ OKTT•OF-SERVICE WELL ❑ GEOPHYSICAL WELL <br /> ❑ BOIL BORING R <br /> /DESTRUCTION: _ <br /> ////// •��• oi&j k9- <br /> La <br /> ✓ /6l. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFlCATION6 <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION A <br /> ❑ DIA.OF CONDUCTOR CASINO <br /> DOMESTICIPRVATE 11GRAVEL PACK/SIZE TYPE OF CASINGISTEEIJPVC U <br /> ❑ PUBLICIMUNICIPAL 11 DRIVEN DIA.OF WELL CASINO D <br /> DEPTH OF GROUT SEAL <br /> ❑ IRRIGATION/AG 11 OTHER OTHER GROUT SEAL INSTALLED BY R <br /> GROUT BRAND NAME E <br /> MONITORING`C%&4f t4.t+t� GROUT SEAL PUMPED: 11Yr ❑No CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No E <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> S <br /> PROPOSED CONSTRUCTIDTT/DIILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE <br /> OTHER <br /> 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL S£DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIN PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIMNO OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 10 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORIOYIAN's COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 4"Dun$IN ADVANCE FOR ALL REQUIRED IN81 ECTIONS AT i2oS1 4MJR2l. COMPLETE DRAWING A7 LOWER AREA PROVIDED. <br /> Stoned X Tift �yl?/L✓'D <br /> '��'C-'�"� yK5 l/'!11'11(/ Oate /8 <br /> PLOT PLAN Slaw to acids)Neale 'to <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, <. LOCATION OF HOURE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OIJTUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNF.8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.WCLUDINO COVERED AREAB SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOININO PROPERTY. <br /> E; <br /> LE. G <br /> N <br /> � Nof � <br /> q ' �sPs <br /> '(►UPSJ <br /> �v Mw--3 <br /> rso �-CAt ' <br /> ...........:..... ...... ... ........... <br /> .. <br /> DEPARTMENT USE ONLY <br /> Applleellen Aeeepled By 1 Date <br /> Grout(ropeelton By `'�/ Date Pump lnepaetlen By Data <br /> Dealnrctlen Impactbn By I4 '` 1 Data <br /> Comment•: 1.t/ ,te <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXffCASH RECEIVED BY DATE PEAMITISERVICE REQUEST NUMBER INVOICE <br /> Pub.Health Serv.-Enviro.173(3/96) <br />