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.I�'i'Vj1� NA!'r APPLICATION FOR WELL/PUMP PERMIT <br /> t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> OCT U 91998 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468m3420 <br /> �t''.JM1i1NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> r'UBLJC HFA.LTH GEPNICES <br /> iJV i;CNl.1FP;TAL HEALTH ']IVISIOI1 (Complete In TripRestel <br /> APPLICATION 15 HEM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 19 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 91115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODRESSNR,A/ANI 41 �Ok; rG SF//X?yyQAMEN�U �� CRY s-aCLTetJ PARCEL 6IZE/APNI 07J <br /> OWNER'S NAME C_'/✓Ll�eGi✓ �.PGsYAG'✓'S L.l'J AW(/ ADDRESS A# /30X� 60Oy MOREI ��JZY/ syI- G1p� <br /> CONTRACTORe�V&77A" — � Ljy�P. ADDRESS 9/&/ C&4gY, 9V uu 720763 RIONE I (9/c) b3/ - >3� <br /> eue cGRTrwcrOR ,C7iQ✓ 4pp.. s;/,7�770,✓,1 ADonESB '9 ("j (FNTPALyAK�L'03�PWJ C# S�z/LJ� BONE # / <br /> TYPE OF WELL/BUMP: 3 NEW WELL ❑ REPLACEMENT WELL WJ MONROWNO WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑ New ❑ R olr N.P. DEPTH RUMP SET_FT. FIRST WATER LEVEL O <br /> (TYPE OF PIMP( <br /> ❑ OVT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ 601E SPRING B <br /> ❑ DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION57 DIA. OF CONDUCTOR CASING O <br /> 11DOMEOFICIPPVATE 11 GRAVEL PACKISIZE TYPE OF CASING/STEEL/PVC �S'Ff�bd/O flVC DIA. OF WELL CASINO �Z O <br /> ❑ R/OLICRMUNMIPAL ❑ D VENDEPTH OF GROUT SEAL ✓�/ r SPECIFICATION R <br /> �❑/JWUGATIONIAO OTHER GROUT SEAL INSTALIEDBY g ,4AXd &!j 7/#.>/ GROW BRAND NAME E <br /> L'J MONITORING GROUT SEAL PUMPED: '0 He CONCRETE PEDESTAL SY DRILLER: Ely" ❑ Ne s <br /> APPROX. DEPTH -�r / �jI LOCKING CHESTER ROX/STOVE RPE1_ s <br /> R10PobEO CONeTR1UCTONIDIRWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREOY CERTIFY THAT I HAVE PREPARED THIS APPICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND nULE6 AND <br /> REGULATIONS OF THE SAN "AWN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERIMPANME OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED, 1914ALL NOT EMPLOY PERSONS "ACT TO WORKMAN'S COMPENSATION LAWS OF CALNORMA.' CONTHACTOR'S HIRING OR SUSCOWRACTIN I SIGNATURE CERTIFIER <br /> THE FOLLOWING: ' 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS BUSJECT TO WORKMAN'S COMPT NBARON LAWS OF <br /> CAUFOPSA.' THE APPLICANT MUST CALL M NOMAS IN ADVANCE FOR ALL REQUIRED IRS#FCTIONO AT 13OS14YJB]S. COMPLETE DRAWNO AT LOWER AREA PROVIDED. <br /> alc,.ea x � � one el�oLOGNsTDere /O —S `jd <br /> FLOP MAN BR.v. to 908101 eeele a 0 30 <br /> 1 . NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. N. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> I. OUTLINE OF THE PROPERTY, GIVING mMENMONS AND NORTH DIRECTION. = 3U / EXPANSION OF BEWAOE DISP06u OYSTEMS. <br /> O. DIMENSIONED OUTUNF9 ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WRHIN RAQRUS OF ONE HUMS110 FIFTY FT. <br /> 6TRUCT F ES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING FFDPLRTY. <br /> \ _ _ <br /> I <br /> DEPARTMENT USE ONLY ,NY, <br /> M+ },Nt <br /> Aepecallen A"worf BY �S ' <br /> Oreul Impmlbn BY <br /> Dole Rene lmpeeSen BY Del. <br /> DeIS <br /> Omnrc(len Inenmlbn By <br /> I Cemmw / ;q - <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC I ASH RECEIVED SY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> ati� l �r - 0� � r8� <br />' I <br /> Pub 4ealth SeN. - Enviro. 173 M97) <br />