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i � it 6-Od-1997 11 : 19AM FROM p 1 APPLICATION FOR WELLIPUMP PERMIT PAYMENT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 JUN 0 6 1997 (209) UB-3420 SAN JOAQUIN COON FY NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED PUBLIC HEALTH SGRVICES (Complete in Triplicate) ENVIRONMENTAL HEALTH DIVISION APPLICATION IS HERE BY MADE TO THE SAN JOAOUfN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESS/ORAPNII Rftc-ABY bt1MP Sj�e crry ItcL4-, CA I-,�<- . IIT} PARCEL SIZE/APN! OWNER'S NAME VV I'LL RM be PC>l.l La ADDRESS'-j35(- TC-AAACc -�K, SaCKrft I/ C�4 9S21ZPNONE s 209-465-3+8', CONTRACTOR E>ZM-►'�� n/C. ADDRESS 155 0440�14AtiL I Sth* BODYDICT CAPHONEPHONE a,9l6-1,a`+-937f� sUB cONTRACTOR 6kJV l(RC7yN tAexT)FL_ I RfJL A'S`�C'JIRt--� ADDRESS 3 01 I TWN PALM�A?�s.CA 9S LGIt 69 57 7C PHONE*4J$-"?--?1.7po TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL F ❑ OTHER ,5C>i L (C=E-oPF- Dow, , ❑ INSTAIIATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL IJ ❑Naw 11Repair H.P. DEPTH RUMP SET FT• FIRST WATER LEVEL 0 RYPE OF PUMP) ❑ OUTaF-SERVICE WELL ❑ GEOPHYSICAL WELL a ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WE L CONSTRUCTION SPL-,-f,IFICAT_IONX Q ❑ INDUSTRIAL ❑OPEN RoTTONI DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOME$TIC/PRIVATE ❑GRAVEL PACKISRE TYPE OF CASING/STEELIPVC DIA-OF WELL CASING p ❑ PUBLICAAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MoNITORNG GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Y"a ❑No s APPROX.DEPTH - LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTION/DRIWN13 METHOD: MUD ROTARY AIR ROTARY AUGER CARLE OTKIEFL PN 61m ninT N,ar4MC-f� I HEoE6Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING.'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORMA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORWAN'S COMIPMSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RCOUIRED 045MTIONS AT(20!)4684423- COMPLETE DRAWING AT LOWER AREA PROVIDED. signed x 2M�L/cit, CMAI \ Title tPgsz�Yec ENG:Nee,,z Data PLOT PLAN(Draw to Soela)Seale 'to 1. NAMES OF STREETS OR ROAD$NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2- OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM&. 3. DIMENSIONED 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 WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. :... : ...:....:.. .<.............;.......:............:.... .. .. .. w ...... .. .... .. .. ..... ....... ..•.. ...... .. . ...... . .. ... .................:.....:....... .. .. .. .. .. .. ........................... ......... .. ............ ............. ............................ .. .. .. .. .. .... i : t .... ........................ .. .. .. .. .. .. .. .. .. .. ...... .. .. .. .. .. .. .............:......:..... ......y......:... .. .. .. .................. .. .. ................................. .. ....... .... . ....y..... .,..... .. .. ...... .. .. ......... ....................................:....•.Y........... .. .. .. .. .. .. .. ..... .... ....i... ....:.............:.......:............ .. .. .. .. ....... .. .. ... .. . ....... .. .. .. .. Y.. ..t... ...... .... ...... .' u ...f... .. ... ...... ........................................ .................. .. .. .. .. .. .. .. .. .. .. .. .. .. ......... 1, .......v.. .... f� ( DEPARTMENT USE ONLY I - ApPlicatbn Accepted By 1.I I ...///''��^,^` Uete l,P l Area Grout impeotion By Date Pump Inspection By Dat" Dattw ion l.sp"ction By Dame Commema' ACCOUNTING ONLY: AID( FACT PE CODES FEE INFO AMOUNT REMITTED CHECKN/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NuwBER INVOICE