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APPLICATION FOR WELLIPUMP PERMIT <br /> SCWAQUIN COUNTY PUBLIC HEALTH SCES <br /> ENVIRONMENTAL HEALTH DIVISIO S <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (RMIT 468-34 10 ORIGINAL <br /> NOW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM RATE ISSUER <br /> (Complete In Triplicstel <br /> APPLICATION IS HEM BY MADE TO THE SAN JOAQUIN COUNTY FOR PERMIT TO CONSTRUCT ANOMR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT/TRUE CHAPTER 977-1116.3 AND THE STMOAMS OF BAN JOAQUIN CO�UQNJTY P-UBUCHEALTH SERVICES,ENNRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APNI 6 /N ) V e r- CITY V Y/1t%I Ile-, PARCEL SIZEJAPNF 73 <br /> Se Jwg b>` (SDI;D; /900 Pewe 11 <br /> OWNEWSNAME C/6bm,.)d y T• i'1/ee4 95608-/897 RIONE 9_,5/0 -(S]-e/SQ0 <br /> CONTRACTOR ADDRESS LICI FHONE0 <br /> eva coNTRAcroR <br /> T9.C97?/17eFrvneks rr nJa um oL 1`�urr� �D. wonEBe_ nhe hp$el C' me /7768! RIONE1707-$d3 <br /> NPEOF WELLIPUMP; C2 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLS ® OTHERG/[u F7XTY'¢c-/ 1-10 .J <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CPOSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL e ✓ <br /> NGP}OS ❑N.11I •I' Hp. DEPTHNMPSET $0 FT. FIRST WATER LEVEL 0 <br /> (TYPE OF PUMP) <br /> ❑ OUT OF WELL ❑ GEOPHYSICAL WELL i ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION (� 1DIA.OF CONDUCTOR CASING A)1A 0 <br /> 13DOMESTICAM1UVATE ®GRAVEL PACKISIZE /& TYPE OF CASINOIST(ELfPVC SC 14 S0 P//C DIA.OF WELL CASING N q O <br /> ❑ PUBLICRAUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL .?O Z SPECIFICATION L R <br /> 11 IRRIGATION/AG �❑� OTHER GROUT SEAINSTALLED BY :t) -j Ile r GROVE BRAID NAME A)Pj L 0I YM PN� E <br /> ® MONITORNGIAFX4Fae LT-A GROUT SEAL PIMPED: ®Ys (IN. CONCRETE PEDESTAL BY DRILLER:®Y« ❑N 5 <br /> APPROX.DEPTH 90 , LOCKING CHESTER BOX/STOVE RPE )/(CS s <br /> RU <br /> PROPOSED CONSTCRRW <br /> ONIONG METHOD: MUD ROTARY AIR ROTARY AUGER CA—BLE OTHER <br /> I HE•IEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOM WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,ANO RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN TNS PERFORMANCE OF TIIE VMw FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUB.CONTRACTIHO SIONATURE CERTIFIES <br /> TIIE FOLLOWING: -I CERTIFY THAT RI THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I%HALL EMPLOY PERSONS SUBJECT TO WORKMAN'/COM6E216ATION LAWS OF <br /> CAUFORNIA.' THEAPPLICANT MUST <br /> TCCALL <br /> ,2e HOURS N,A/DVANCE FOR ALL REQUIRED rI/NSPIRTMON^E AT 12001 4400 22. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> SI.—f X ( .('ej _ „�72r'� TIB. _1 i k YM�e T Ma-711 AI P I` D.,. r <br /> /POT PLAN ID'.le eode)Baae 'to <br /> 1. NAMES OF STREFT8 OR ROADS NEAREST TO OR BOUNDING THE PMPERTY. e. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR RROMSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED E. LOCATION OF WELLS US OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPiC�a OE <br /> XE <br /> 14P lq� bo- c' ► ed. FFB 23 1998 <br /> SAN JOA WIN SEF:IGCa <br /> PUBLic HFAL LT DIVISuotl <br /> �NVIRONMENTFL HEP <br /> DEPARTMENT USE ONLY /T)�/�J(��' <br /> APPlleellon Aeeepled BY D.H ���� C `• Des. v`✓`-� <br /> G'.0 In.peCllen a, D.te Pump In•P«nen BY D.4 <br /> Urlrmllen IMwll.p 8, DRe <br /> cemme.e. C(�/'{✓r ,ate uxe, yx�e/.hoa'� , �9t�� Qz J�/d�— � �.� <br /> v U ' <br /> ACCOUNTING ONLY: AIDE TACO <br /> PE CODER FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PERAIITISERVICE REDDEST NUMBER INVOICE <br /> 290 1AW FIS46 4 C> 3 <br /> Pub.Health Selo.-Enviro.173(1/97) <br />