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APPLICATION FOR WELL/PUMP PERMIT <br /> oilp '� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC F­ En U." <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 MAY 18 1999 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEUWi r i ir- IAS r'EALI� <br /> ICemple(a M Triplicate) n _ �:,�I r ; qFR\/ICES <br /> APP.ICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.Title APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAFFER 8-1116.3 AND THE STANDARDS OF SAN JOADUIH OVNTY PVBHALT EFRVICEB,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN! I ,(& � I ~ �� PARCEL SIZE/APNO C� ^ <br /> 0 I ADDRESS ff'OWNER'S NAME CUC! G ?"P�HONPEHOI N/E�I J��/o <br /> I <br /> CONTRACTOR ACL"r-eA /& Vj( *hjjR��'( ADDRESS 11A9 <br /> SUS CONTRACTOR ADDRESS LIC! RHONE! <br /> TYPE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL At ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! J <br /> ❑New❑P.P.1/ H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OUT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL! Lr'SOLI BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ( DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELIPVC DIA.OF WELL CASINO D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ?J/ ` SPECIFICATION R <br /> ❑ 1 OATION/AO ❑OTHER GROUT SEAL INSTALLED BY t GROUT BRAND NAME <br /> 1", O GROAT REAL PUMPED: ❑V« ONO CONCRETE PEDESTAL BY DRILLER:❑Y« CIN. 5 <br /> 42 APPROX.DEPTN S LOCKING CHESTER BOX/STOVE RPE S <br /> PROPOSED CONSTFIUCTIONtMLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER_ <br /> I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE$.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIIH COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S 1HIPoNG OR SU"ONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA,- TH�EPPJJCANT MUST HOURS IN ADVANCE FOR ALL REOURED INSPECTION$AT 12001,4eeJ423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> $Iemd X�i��Y i�W� TIN. C1>'/T sT -6-I 15 99 <br /> Dat. <br /> PLOT FLAN 1Dr.w to 90.401 Be.l. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF(HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,OIVNM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 7. DIMENSIONED OUTLINE$AND LOCATION OF ALL EXISFRM AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ... ... ... ... ._ ..... <br /> :. _... <br /> : .. ..... .. <br /> 1 <br /> DE►MTMENT USE ONLY Q G( <br /> Application Accepted BY 6 <br /> Grout Impeelbn By Dot* Q Pimp Impeetlen BY Dots <br /> De.utctlen Impxtlon Br h, ----j, D.t. <br /> Comment.: e- p <br /> a / /t- -'( t ,,;Z7(./) - <br /> ACCOUNTINO ONLY: AID! FAC! <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK!/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> DI �' a z 71 lw�- 0 5 DZoBS <br /> Pub Health Serv.-Enviro.173(1/97) <br />