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PPLICATION FOR WELL/PUMPPERNAh <br /> © Cly SA�AQUIN COUNTY PUBLIC <br /> ICHEALTH SCES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (�f j V,,,.00304 EAST WEBER AVENUE, STOCKTON, CA 95202 y <br /> P^ £ ✓� E ^yp'f 468-3420 L <br /> MON-REFUNDABLE PERMITERMIT EXPIRES 1 YEAR FROM OTE ISSUED <br /> (Complete In Triplikate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WWII SAN <br /> JOAOUIN COUNTY DEVELOPMENT TDyLE;CHAPTER 9-1115.3 AND THE STANDAPFIR OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DM/SION. � ✓� <br /> JOB ADDRESSOR APN 6723 60 un <br /> �� CITY (,��.fGr 6��/l^PAR.C-E�L�BIZEIAPNI�[��elpQ�g,t�n Drl..., <br /> OWNER'S NAME�'•J WCJ UPJ ADDRESS O C - / '-&"y o4t RHON�E�1 "d <br /> CONTRACTOR ADDRESS sOL/ S `• PHONE� <br /> BUS CONTRACTOR 4 Lod /Fr-N-M1 ADDRESS S'dnc�Jc.�.('H 4sooe MgV/?769 PHONE IJZY2y(,S-�J/ <br /> TYPE OF WELL/PUMP: Id NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL E ❑ OTHER <br /> ,,��HH ❑ INSTALLATION El WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ® VAPOR EXTRACTION WELL IF ✓E J <br /> NL, ❑N.0Inep.1, N.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMPI <br /> ❑ OLFT-OF-SEINIOE WELL ❑ GEOPHYSICAL WELL I ❑ SOR BORING e <br /> ❑DESTRUCTION. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPENBOTTOM DIA.OFWELLEXCAVATON J9-0/0"// " DIA.OF CONDUCTOR CASINO N O <br /> ❑ DOMESTICIPNVATE ❑GRAVEL PACK/SIZEPP TYPEOFCASING/STEEL/PVC NYC SOL,( S/D GIA.OF WELL CASINO Z 4 O <br /> ❑ MOM MUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL ((11 X� 6 1 // SPECIFICATION 1 / J ./� R <br /> q❑qIM MOATIONIAO /❑OTHER GROW SEAL INSTALLED BYV46CO+LH2LM//✓- OROLFT BRAND NAME Ce W iat T-p 4n&7,/e. E <br /> LCY MONITORING/� /O[j(yy, GROUT SEAL PIMPED: ®Yr ❑Ne CONCRETE PEDESTAL RY DRILLER:❑Y- ®Ne 5 <br /> APPROX.DEPTH &0 LOCKING CHESTER BO%/STOVE RPE�VPS 5 <br /> PROPOSED CONSTRUCTIONMPILUNO METHOD: MUD ROTARY AIR ROTARY AUGER x CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATIVN AND THAT THE WOM WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LIOENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PFREORNIANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 19 ISSUED,ISIHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HINNO OR SU"ONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE APPLICANT MUST CALL 24 HONK IN ADVANCE FOR ALL REQUIRED(IN�SP IRINT.8TAT 12081 400-/182'2.. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 1q.,r'. Del. d-a4 <br /> c <br /> PLOT PAN L..1 ep.l. •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROIERTY. 4. LOCATION OF HOUSE SEWAGE DRIMBAL SYSTEM On P OMSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMB. <br /> G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WNHN MONS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOIMNG PROPERTY. <br /> DEPARTMENT USE ONLY <br /> Appne.Hbn AP.wteH BY <br /> Gr.0 Me Ux By D.Re Rmp 1O.P.O.O By D.1. <br /> DwO.1len I.P. ur,B/Y// /'/ Dae <br /> Cemmae.! �Gl c, ' VVZTEn <br /> ACCOUITINO ONLY: AID/ FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK2GASH RECEIVED NY DATE PENM,ITHERVICE REQUEST NUMSEM INVOICE <br /> Z9CI SV o! 3Z <br /> Pub.Health SEN.-Enwo.173(1/97) <br />