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APPLICATION FOR WELLIPUMP PERMIT SAN JOAO COUNTY PUBLIC HEALTH SERVICES ® ��g ENVIRONMENTAL HEALTH DIVISION 520 !Ir/� I '�nl JNr P50, BOX SM 304 EAST WEBER AVENUE, STOCKTON, CA 9 (209( 4683420 OCT 2 51996 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Gampl6t6 In Trollents) ENVIRONMENTAL H APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOR( DESCRIBED. TARS A NVIRO A MENTAL VIITII SAN JOAQUIN COUNTY DEVELOPJ6IEI�NF TITLE, CHAPPTTE/LR,D.-1 I6.3 AND STANDARDS OF BAN JOAQUIN COUNTV''FPUBUC HEALTH SERVICES, ENVIRON R A JOB ADDRESS/Oq APNE F`T � rj'T( � FI5C� • ILJcnyfI CIT-YI / Q PARCEL SIZE/APNF OWNER'S NAME - Akhajel O (1C1��P �nA ADDRESS ' F C II�tp PHONES CONTRACTOR RafuVrA +P A �/A I��f 17Lr Imo, r /1L ADDRESS I�2OC W. / r V(C ��rIQ 11C O O CZ PHDi1E F /l 02 SUB COMPACTOR �5 Ire kI �� AODRE68315E m;talo AA�� 117110E pLC PHONIE TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 4 yq OTHER �C ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL E J ❑ New ❑ Rapelr H,P. DEPTH PUMP BET_FT. FIRST WATER LEVEL G (TYPE OF PUMP) ❑ 1Q1 OUT-UF-SERVICEWELL GEOPHYSICAL IN BOIL HOPING 2. R ❑ DESTRUCTION: E TYPE OF WELL CONSTRUCTION 6PECIFICATIONS1 �1 AA A ❑ INDUSTRIAL ❑ OPENHTO OTM DIA. OF WELL EXCAVATION I. 12S'e VIA, OF CONDUCTOR CASING JUM D ❑ DOMESTICIPRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASINO/6TEEL/PVCy—A)I L DIA. OF WELL CASING _(y�IQ D ❑ PUBLICOAUNICIPAL ❑ DRHVEN DEPTH OF GROW SEAL 1—T E� SPECIFICATION 1 T p pp❑TT IRPIGATION/AD ❑ OTHER GROUT SEAL INSTALLED It 5 GROUT BRAND NAME 6A{ Rn�I T... µ cC,WeT}E Lca MONITORINGGROUT SEAL PUMPED: 11 Yet IBNO CONCRETE PEDESTAL BY DRILLER:-A Yw ON* S APPROX. DEPTH �Q LOCKING CHESTER BOX/BTOVE PPE! A S PROPOSED CUNST11UC1IONIDISUINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER QO I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY OPOINANCEe, STATE LAWS, AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY, HOME OWNER On LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING: 'I CERTIFY THAT IN THE PERrORMANCE OF THE wow FOR WHICH THIS PEnMIT Ie ISSUED, 191/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' COMRACTOR'S HIRING OR SUDCONTRACTINO SIGNATURE CERTIFIER THE FOLLOWING; • I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 19 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION "We OF CAUFORNIA: THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED IN SIPHONS AT 12001400 A22, COMPLETE DRAWING AT LOWER AREA PROVIDED. m SIPd X 4p AAq /.1/� "r . / Title \i' Q 1A5� 5; O.,e PLOT PUN loraw.to Sahel Seale • l0 1 . NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PIUPEPTTY', GIVING DIMENSIONS AND NOUN DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMS, 3. DIMENSIONEV OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALSH. ON THE PROPLRTY On ADJOINING PROPERTY, DEPARTMENT USE ONLY ApPllpallen Acoapled BY " - ' LJAA Dole �' p6 Area Grow ImPeellon BY Oala Rn•.P Pn•Pectien 0Y UNa D"wre len Inspection BY Data Cewmews: ACCOUNTING ONLY: AIDS PACO PE CODES FEE INFO AMOUNT REMITTED CNECKNICASH RECEIVED BY DATE PERMITIRMWCE REQUEST NUMBER INVOICE i"0 / alb ��G•� !� �llb / D Pub, Health Servs - Envlro. 173 (3/98)