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PLICATION FOR WELUPUMP PERMIT <br /> SA OUIN COUNTY PUBLIC HEALTH SES <br /> ENVIRONMENTAL HEALTH DIVISION* V <br /> �+ 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 O'1.0 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED UU""�� <br /> ICGRIPI618 In Tri Hcmtvj <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AMC=INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TRUE;CHAPTER 9-1115�.//3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PU/BUC HEALTH SERVICES,ENVIRONMENTAL HEALTH D SIGN'� „0 <br /> JOB AODRESSIOR APNI331 t �Pm.�ct CRY Jl`0lnf' PVK-F�. <br /> PARCEL BIZE/APN/_�� <br /> F4 D w.a� 'r.Lcfwl-KS LSoetirJ /qoD nGrue.)>s+.,/2 Fig. <br /> OWNER'S NAME T'� rR L, / U F O.L ,YP[V.J ADOREBS_ �._e,.1//l PA 9VL!)Q PHONE 570)6S`_r <br /> CONTRACTOR 4CChp1 �.„Ji <br /> =p <br /> SUB CONTMCTORTOMSADDRESS / c�'JAy sQl1CI PHONE I <br /> ADDRESS eAi eA <br /> UCf706 -9? PHONE 9/6 8.51-y0/[ <br /> TYPE OF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT PIEPAM ❑ VAPOR EXTRACTION WELL I <br /> ❑New❑Rep.1, N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D <br /> RYFE OF PUMPI <br /> ❑ OUT-OF-SERVICE WELL 11GEOPHYSICAL WELL I Bolt BORINGyrt B <br /> El DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q A <br /> 11 INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION z- ""C,K DIA.OF CONDUCTOR CASINO A)A- 0 <br /> ❑ DOMESTIC"WATE ❑GRAVEL PACKISIZE TYPE OF CASMISTEML C DIA.OF WELL CASING / D <br /> ❑ PU9LICMUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL x'�g^QTOToi L'/P/17NSPECIFICATION (IenM, /2gD At"l- R <br /> ❑ IRRIGATIOIUAG ❑OTHER GROUT SEAL INSTALLED BY I%V'g OR I I IF✓l GROUT SRANO NAME A)14 E <br /> ❑ MONITORING J//�L GROUT SEAL PUMPED: IA Yy ❑Ne CONCNETE PEDESTAL BY DRILLER:❑Yw I Ne N✓�- S <br /> APPROX.DEPTH <'s-c r I LOCKING CHESTER BOX/STOVE PIPE <br /> // 5 <br /> PROPOSED CONSTRUCTIONRMSLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER dr.'-A �N6� <br /> I HEREBY CEnTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> PEGULATIONB OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,I SMALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,1 WALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOUR{IN ADVANCE FOR ALL REQUIRED neeIINSPE/C ION@ AT MOnI L400N 3423. COMPLETE DRAWING AT LOWER AREA AgVIDED <br /> Glex c.-��� \lam�� L_Tur. 'li7"e. �MiPG^ /'lOm an P,r� Do.. 3/IX7 g/90 <br /> PLOT PLAN ID,.w w%W.1&.1. le <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNCHED FIFTY ET. <br /> 6TRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PMPFRTY. <br /> M -9p 8fL4. a� ec(,. <br /> DEPARTMENT USEONLY 7 � <br /> Avvllc.Ilen Aee«I.d BY D.I. f/ <br /> GreN Imo«Ileo By D.I. Pump Imo«tlen By Dae <br /> Sea.«Ileo In.v«nen Br (Ir^ /^ _ ml. <br /> Demma,w <br /> ACCOUNTING ONLY: AID/ FAC# <br /> PE CODES FEE INTO MOUNT REMITTED CHECKMAIN RECEIVED NY TE PEINIITISF/LVICE REQUEST NUMBER INVOICE <br /> 2 03aV6 7 Co-i O/5 Z5 <br /> Pub.Health Saw.-Enviro.173(1197) <br />