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APPLICATION FOR WELLJPUMP PERMIT <br /> SEAQUIN COUNTY PUBLIC HEALTH SEES <br /> ! ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> `209' 4.3420 ORIGINAL <br /> WON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> (ComplatB In TApl•Ie%bl <br /> AFPUCATION IS HEM BY MADE TO THE SAN JOAQUIN COUNTY FOR PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOM DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAN <br /> E7ENVIRONMENTALAL HEALTH DIVISION. <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1116.3ANDTHE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, <br /> JOB ADDRESSION ANE 1?7 / J ✓ C CITY PARCEL SIZEANI Vy /y-VI <br /> _Cj+RA.! ClaRIONEI cSO -(S.7- <br /> OWER'S NAME C/ T Dry <br /> O <br /> O <br /> // CONTRACTOR ADDRESS UCI PHONE 3 <br /> 6 OD a as octet puo( <br /> SUB CONTRACTOR,(d)P1rne-.�s�r'/Z'nla amaC 1�L,.n.�' 00 ADDRESS 9&h r��tH73 Uc• /7768// RIO/NE1707-$73�/� <br /> TYPE OF WELI/PUMP• ICJ NEW WELL �❑ REPLACEMENT WELL ❑ MONITORING WELL I ® OTHER ✓U <br /> - XThaCT/04J <br /> //� ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS­cONNECT REPAIR ❑ VAFOR EXTRACTION WELL F <br /> �fUNGIi-GS ❑N..v❑Repeir HD. DEPTH PUMP SET $0 FT. FIRST WATER LEVEL O <br /> TYPE OF PUMPI <br /> ❑ OUT OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL El OPEN BOTTOM DIA.OF WELL EXCAVATION �y DIA.OF CONDUCTOR CASINO /AI/iT} O <br /> ❑ DOMESTIC/PRIVATE ®GRAVEL PACK/RITE S /O TYPE OF CASINGISTEEL/PVC 3(14 8o PYG DIA.OF WELL CASINO <br /> ❑ PV81ICBAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL- <br /> ?O T SPECIFICATION L L R <br /> 11 IRRIGATION/AG /❑�/ OTHER GROVr SEAL INSTALLED BV �NI ��e r GROUT BRANO NAME A1PR L- O B 1M P-n1 L E <br /> ® MONITOMNG/,F><4rmC]-t*A GROUT SEAL PUMPED! ®Ys 11 N- CONCRETEPEDESTALBYDRILLER:®Y« ❑Ne 5 <br /> APPROX.DEPTH 90 , <br /> LOCKINO CHESTER BOX/eTOVE RPE yes 5 <br /> —J-'--' <br /> PROPOSED CONSTRUCTION/ tUNO METHOD: MUD ROTARY_AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY TIRAT I HAVE PREPARED THIS A{'PIICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AOENT'B SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S"HUNG OR SUB-CONTRACTMG SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PEReONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE APPLICANT MUSTCAM3A ^8,I,N�ADVANCE FOR ALL MOUNTED INSPECTRINS AT 13051 ABS/ 22.. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 6I.—I x <br /> PLOT PLAN I01.w le Soa.l 6c.1. 'le <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 3. OUTLINE OF THE PROPERTY,DIVING DIMENSIONS AND NORTH DIIIECTION. EXPANSION OF BEWAOE GISMIIAL SYSTEMS. <br /> S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> G.STRUCTURES. <br /> INCLUDING <br /> AND LOCATION OF All EXISTING PATO AND PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 6TRUCTVREB,INCLUDING COVERED AREAE SUCH AS PATIOS,DRIVEWAYS,ANO WALKS. <br /> PAYMENT' <br /> M qP �f�cZ c�► ed. R �rv� r <br /> FEB 2 3 1998 <br /> 1 <br /> LSAN dOA RUIN cciu J Y ....... <br /> DEPARTMENT USE ONLY ENVIRONMENTAL FJEAf uIVISKI A<o O <br /> AOPlicellen Acaepled By Oaa 'JZ � <br /> O�eul lneeeeBen By <br /> Dna Pump IvPetllen SY Dae <br /> D.te <br /> Uo.�..knee u..Pec600 By <br /> cammT.l.: <br /> ACCOVNTINO ONLY: AIDI FACT <br /> LS FEEINFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DAT PEV.OTISERVICE REQUEST NUMBER INVOICE <br /> r o3 23 <br /> Pub.Health Serv.-Enviro.173(1/97) <br />