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APPLICATION FOR WELL(PUMP PER <br /> S�AQUIN COUNTY PUBLIC HEALTH SMa <br /> ENVIRONMENTAL HEALTH DIVISIO <br /> PCES <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468.3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplklbl <br /> APPLICATION IS HE RE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDron INSTALL THE WOW DESCRIBED.THIS APPLICATION ISCCOMMIANCE"It SANJOAOUIN COUNTY DEVELOPMENT TRUE;CHAPTEIR 9-11115.0 ANNDD THE STANDARDS OF SAN JOAOUIN COUNTY PUBLI1C HEALTH SERVICES,ENVIRONMENTAL HEJOB ADORESBR)fl APNl�76 �/ 0//ll ( PA)/iP ✓ CITY I(/Yl 6E/�yt�NPARCEL 812/..NSDrClPa.l.',.9�e <Nae✓Ls SD Ar )nW Va l tevc Y, /� e. <br /> OWNEn'S NAP Ile /d T !J d /+ ! t ! ADDRESS <br /> CONTRACTOR (I / ADDRESS UCI PHONE/ <br /> SUBCONTRACTOR,�](2'0C,gru 1Ivv ADDIM" .SiMb 3t q 95WO.T LK:eC571S/116➢,,MNE e�09-5�(,S-phi <br /> TYPE OF WELL."MP: K1 NEW WELL ❑ REPLACEMENT WELL Id MONITORING WELL 1 ❑ OTHER <br /> n <br /> 11 INSTALLATION ❑ WELL SYSTEM REPAIR 11Cnos"oNNECT REPAIR 11 VAPOR EXTRACTION WELL 1 <br /> /V/A ❑N.. 11 nw.1'OF PH.P. DEPTH FUMP SET�/LF , FIRST WATER LEVEL O <br /> NYPE UMP( <br /> ❑ OUT-0F-SERVICE WELL ❑ GEORIY93CAL WELL 1 ❑ COIL BORING S <br /> 11 DESTRUCTION: <br /> WINGED USE TYPE OF WELL CONSTRUCTION 6PECIFICATIONe <br /> 1-1 INDUSTRIAL I❑Iqq OFEN BOTTOM DIA.OF WELL EXCAVATION /0 DIA.OF CONDUCTOR CASING AJA <br /> ElDOMESTICR9N (0 <br /> VATE GRAVEL PACK/SIZE# 6 TYPE OF CASINO/6TEEL/PVc SYO �`�. DIA.OF WELL CASINO (fin p D <br /> ❑ WOUCRIUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL TSO/ 6PECIFICARON R <br /> ❑ IPRIOATroN/AG ❑OTHER GROUT SEAL INSTALLED BY_ r%Ile N^ GROW BRAND NAME AAIQ j CIqe kM e/ e E <br /> IN MONITORING GROUT SEAL PUMPEOt ®Yn [IN. CONCRETE PEDESTAL BV ORILLEfl:p Y.. ❑Ne S <br /> APFROX.DEPTH 8O LOCKING CHESTER BOX/STOVE RIFIYP� 8 <br /> PROPOSED CONSTAUCTIORIDAILUNO METHOD: MUD ROTARY AIR ROTARY AUGER Y CABLE OTHER <br /> I HEREBY CERTIFY TIIAT I RAVE WIEPARED THIS ARNICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE FERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,1911ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS MANUT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENMTION LAWS OF <br /> CAUFOnN\IA.' THE AFPUCANT MUST CALL 21 HOURS IN ADVANCE FOR ALL REQUIRED�INSMRONS AT CRISP/4100 T22. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Do. <br /> v l <br /> PLOT FLAN NDrnv le 6<WI Bele <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On Rrorro6ED <br /> 2. OUTLINE OF THE RMFERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> O. DIMENSK)NED OUTLINES AND LOCATION OF ALL EXISTING AND RbPOSEo S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,ANO WALKS. ON THE PRPER <br /> UTY OR ADJOINING RgPEnTy. <br /> R <br /> " J A p �If t 0- c' e cc <br /> DEPARTMENT USE ONLY <br /> APPllealen Aeeryl.d BY �_ D.N V✓ /` V NM_-'_!�/eT <br /> Oram loepeetl.n BY D.1. Pvnp In.pxtlen BY p.1e <br /> D..bw6en Imn.m�BY D.ta <br /> -L <br /> ACCOUNTING ONLY: AIDC FAC1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKI/CASH ITEC ED BY DATE INSiMITAHAVICE REGUEIT TR INVOICE <br /> Pub.Health Serv.-Enviro.173(1/97) <br />