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*APPLICATION FOR WELLJPUMP PERM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 0 3 S L u, <br /> (209) 488-3420 <br /> N011•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Camplat*M THP11"181 D`7— Zo <br /> APPVCATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOgR INSTALL THE WOFX DESCRIBE 119 APRICATgN IS MAGE IN COMPLIANCE Wrtll SAN <br /> JOAQUIN COUNTY DEVELOPMENT'TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH S CEO,ENVNgNMEMAL HEALTH DIVISION. <br /> JOS AOOMSBIOR AAPPNNI _ �.�.JfV �.] . th..G�y�.--./S��' CIT.Y�/,S��C/I/C Dom.. p PAIK£LMZE/APN! <br /> OWNER'S NAME.510 ck6z, C�(1M-,.Qpb� d4 yam El'4 /"'Fees ` l/ 'CY-�.. S-�Dl �Lt rSZ�1Z RroNEt n�-1 n <br /> CONTRACTORPL'e.G;--s 1,6 ADDRESS III(/ bo S. �JSa-4S tY.f 1n�y(jCI O �/�JeB SPJH�ONE I (�,'71[���15(S <br /> 'eA1SUGTA ATT /I LA 4-m tj ADDRESS ?<OLL C 11'" 1"F !F'r,SR�"PHONE F 7`��-`�� <br /> —$lMCa}RMETOIT� C� <br /> � 9Z5 <br /> TYPE OF MMMUMP: ❑ NEW WELL ❑ R CEMENT WELL ❑ MONITORING WELL! ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EJRRAcYmN <br /> ❑Naw❑R.PW HP. DEPTH PNAp SET_". FIRST WATER LEVE!!l!T.111111. - 1U�, 110 <br /> RYPE P OF PUM ❑ OVT-0F6EAVICEWELL ❑ OEORIYBICAL�WAE1(�1LL! �'WRBORIN[i L If <br /> ^�IIQB <br /> ❑DESTRUCTION: - �( !, � (J lJ-� CJ I� !.1�IvEti� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION%PECIFICAMNS E A <br /> 11 INDUSTRIAL El OPEN BOTTOM OTA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ aOMESTICMOVATE ❑GRAVEL PACXI E TYPE OF CA8INORITEEUPVC DIA.OF WELL CAIDNG 0 <br /> ❑ PI9UCIMUNICIPAL ❑OW VEN DEPTH OF GROUT SEAL SPECIFICATION 8 <br /> ❑ IPIHIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY BMW BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PIMPED:❑Y. ❑Na CONCRETE PEDESTAL BY OPoLIFR:❑Yw CIN. S <br /> "Max.DEPTH LOCXPNL CHESTER SO%/STCVE PIPE $ <br /> PROPOSED COMSTRUCTIONI IUJNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE^ESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE MW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OROMANCEB,STATE LAWS,AND RULER AHO <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNEA OR LICENSED AGENT'S SIGNATURE CERTIFIES THE PoLLOWING:'I CERTIFY THAT IN THE PEPTORMAME Of THE WORK FOR Yr+IICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' COWMCTOR'8 HIPoNG OR*UB-0OWMCTIM MNATURE CER;IMS <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 38 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORXF.LAM'S COMPENSATION LAWS OF <br /> CMAFOIWIA.' THE APPLIO NT UST CALL 24 HOURS IN ADVANCE FOR ALL REDLINED INSPECTION*AT V10%14403.39. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 00-1 X Tilt. c�Y( //�'1Xh" D.L. <br /> PLOT PLAN OD,—le S.J.1 8 W—' <br /> 1. NAMES OF STREET@ OR ROADS NEAREST TO OR BO NOING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISFT$M SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GMNO DIMEN610NS ANO NORTH DIRECTION. EXPANSION OF SEWAGE CU*QSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROP08£O S. LOCATION OF WELL$WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUMNO COVERED AREAS SUCH At PATIOS,DPoVEWAY9,ANO WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> o <br /> / 0 —� �5. `a .. loc d- vee a <br /> cA <br /> DVAIRTMENT ME ONLY <br /> Apo..O.A. Iw BY L D.1. V lAr.. <br /> G`. BNP.pe.n BY D.I. mpl,Inpwtlan BY <br /> er MI. <br /> — <br /> ACCOUNTING ONLY: AID! FAC) _ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXITAAH R BY DATE PERNOTMIERVICE REOUFJT M 11111 INVOICE <br /> o a /?,9 Lq cL <br /> Pub.Health Sew.•Ermro.173(1/97) ' <br />