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PAYMENT APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION OCT 0 91998 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468.9420 ^ 'BPJ JiHEALTHJJIN COUNSFIVIC NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC HEALTH SER`!10ES 3NVIRONMENTAL HEALTH DIVISION (Cmnpl#(# In Triplku#1 APPLICATION IS (HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR( DESCRIBED. Title APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TRLE, CHAPTER 8`1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADORESS/Ofl// V/ _y� A��P��N��/ 0660 .CCJ47E2 .s�C°IPAmE.uTo CITY `5 pLe �6, ) PARCELSQUAPN/ � 7.f\ 170 6/ OWNER'S NAME' f IZCY �.PO['LrCrS 1 HT�.9 t/ ADDRESS j �O. � JgJ90nLI RHONE I C22r/ fV2 — Oe� cONTRAcrpq (g'i_7JXfiL — ,f�,iy✓ �CP �E^/T' ADD11E66 .3i6°>' GO[� L'agrp/x ^�y(J uC/ �2p753 PHONE #Zflc) b3/ - /36d EUB q[(/,Q/f/%� COMRACTOfl � �� ADONE86 «PJ3 ✓`DZQp({�00 .SZ�L>' PHONEE � Eastman TYPE OF WEL�P: LJ NEW WELL ❑ REPLACEMENT WELL IG MONITORING WELL Iif ve/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL P J RYPE OF RIMPI ❑ New ❑ RepNr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SEnME WELL ❑ GEOPHYSICAL WELL / ❑ SOIL BORING B ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS El INDUSTRIAL pHA. OF CONDUCTOR CASINO p INDUSTRIAL OPEN BOTTOM DIA. OF WELL EXCAVATION ❑ DOMESTICIRUVATE ❑ GRAVEL PACKISRE TYPE OF CASINGISTEEUPVC ��A� YO PVL DIA. OF WELL CASING � �� D ❑ RHBLICRAUNICIPAL ❑/DN DEPTH OF GROW( SEAL_ ..3/ (rM5 SPECIFICATION R I❑�JPHIGATIONIAG L'J OTHER GROUT SEAL INSTALLEDBV 6Ti4 GROUT BRAND NAME E Ll MONITORING GROUT SEAL PIHMPED: 2ym ' Ll No CONCRETE PEDESTAL SY DRILLER: Ely" ❑ NO 5 APRRD%. DEPTH S LOCKING CHESTER BOX/STOVE R4£ / 5 PROroSED CONSTRUCTIONIORIWMU METHOD: MUD ROTARY AIR ROTARY AUGER •/T CALEOTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH CAN JOAQUIN COUNTY ORDINANCES. STATE LAWS. AND RULER AND REGIILAT10N8 OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWmG: 'I CERTIFY THAT IN THE PERTORMANCE OF THE WORK FOR WHICH THIS PERMR IS ISSUED, 181HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{ COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' 1 CERTIFY THAT IN T14E PERFORMANCE OF THE WORL FOR WHICH THIS PERMTT IB ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 14 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION# AT 11081443 11. COMPLETE DRAWING AT LOWER AREA PROVIDED. et#p a X � �/ Title �<O[Oc/s> Data /4 —S 7a PLOT PUN RAaW to Sealel 8ae1e • 4m .JO / 1 . NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 6. LOCATION OF HOUSE SEWAGE D18POSAL SYSTEM OR PROIOSED 1. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. v _ 3U r EXPANSION OF SEWAGE D18FOBAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WRNIN RAINS OF ONE HUNDRED FIFTY FT. STRUCTVREB, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY, T A T I O N �yrrJW�unr t BUILDING �GdL D -Z oswr I DEPARTMENT USE ONLY Applleetbn Aaeepted BYJ�Z /� Geta D I U Mee Crept lmpectb By Date Puny lnapectlen By Dale OatrwUen Impa<tbn BY Dote Commenla: 4!/m w U-,� �s �- ACCOUNTING ONLY: AID! FAC/ PE CODES FEE INFO AMOUNT REMITTED C"CC)l!rpASH RECEIVED BY DATE PERFAIT/SERVICE REQUEST NUMRER INVOICE rel �r — ova Pub Health Serv. - Enviro. 173 (1/97)