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Xs � .. 8-�:_ � •�i; :warm <br /> APPLICATION FOR WELL/PUMP PERMIT '^ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION MAY 18 199 <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 I <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICa1Raletb in TrbDeaul <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TII9 APPLICATION IB MADE IN COMPLIANCE WTTII SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER <br /> ^9-11 111 G.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC�HEEfALTH SERVICES.ENVIRONMENTAL HEALTH O"810N, <br /> 55100 <br /> JOB AODRESS/OR APN/ /7,6, �✓Y' '�/ / GL' CWY /'� PARCEL SIZE/APJI` ��- Zq <br /> `1 L <br /> OWNER'S NAME �T CT 8 j���L /,I ��\� PHONE I <br /> CONTRACTOR 'Y/( L) BS �JV(/YC.f/'! ry�)"cr4CO-7-?PHONE/ <br /> 9U8 CONTRACTOR ADDRESS UC/ PHONE/ <br /> TYPE OF WELUPVMP: ❑ NEW WELL ❑ REPLACEMENT WELL -lr-l"MNFTORINO WELL J-_ Cl OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR Cl VAPOR EXTRACTION/WELL/ J <br /> ❑New❑R.e.h H.P. DEPTH PIMP BET FT. FtRST WATER LEVEL <br /> (TYPE OF PUMPI <br /> �'-0E-QERV)CE WELL /❑.,OEOPHYSt/C�ALJbW,ELL/ 1:1 SOIL SOLING R <br /> DESTRUCTION: � �W'1�7{"- v "" A - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> Cl INDUSTRIAL 0 <br /> OOPEN BOTTOM/'� {/ DIA.OF WELL EXCAVATION S/t 01A.OF CONDUCTOR CASING 0 <br /> C] DOMESTIC/PRIVATE !J GRAVEL PACt(/BIZY `s TYPE OF CASING IST EELPVC ��y 0-z-{ DIA.OF WELL CASINO D <br /> ❑ P/BUC/MUNICIPAL ElRI <br /> DRIVEN (� DEPTH OF GROUT SEAL /r/ SPECIFICATION R <br /> Cl IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ] / E <br /> MONITORING ^Sl GROUT SEAL PLIMFEO: Ye. ❑Ne CONCRETE PEDESTAL SY DRILLER:❑Ye. ❑Ne S <br /> APPROX.DEPTH LOCKING CHESTER 8OX/STOVE PPE S <br /> PROPOSED CONSTRUCTIONR)IILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> [HEREBY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAW$.AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S MONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PFWORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 911ALL NOT EMPLOY PERSONS SUBJECT TO WOM MAN'S COMPQISATFON LAWS OF CALIFORMA.' CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: "I CERTIFY THAT M TILE PERFORMANCE OF THE WOFSC FOR WHICH TNS PERMFT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WOfr"AAN'S COMPE2/SATION LAWS OF <br /> CALIFORNIA." THE APL ANT MUST/CA�LL/�][��JHHOOUURS IN ADVANCE FOR ALL REOUIRED INSFSC TIONS AT 12061 4".Z422. COMPETE DRAWING AT LOWER AREA PROVIDED. <br /> S*-d X�AC�� "- "'lLJ Titl. �G - a <br /> PLOT PLAN IN-to 8ed.1 Se N. "to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.OfV*M DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> ]. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTMG AND PROPOSED S. LOCATION OF WELLS WITT"RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIO$,OFIVEWAY9,AND WALKS. ON THE PROPERTY OR ADJOINMG PROPERTY. <br /> - .: . ._. <br /> . _ . .. ;.. <br /> /� DVwR <br /> ARTENr USE ONLY ^/ <br /> newla.lMn Aoeapted BY 7J�/ D.t. J A-00 i442p /'q- <br /> O,.A IMnxtbn BY O.t. Ptr,e In.e.etlen SY ! DN. <br /> On.tnaetlen I— len BY Da• �� <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECX/1CASH RECEIVED BY DATE Pff"TISFRVICE REQUEST NUNSFR INVOICE <br /> Pub -4eafth Serv.-Envlro. 173 (1/97) <br />