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APPLICATION FOR WELUPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />FILE(209) COPY <br />4684420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Cempbte In Triplicate) <br />APPLICATION IS IIERE BY MADE TO THE BAN JOAQUIN COUKrY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR( DESCRIBED. TIES APPLICATION 18 MADE IN COMPLIANCE WITII SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1115..3} AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADORESSIOR'' A``PNI 1460 T&5 111�L'�'K 'm/ Z ' CIQTY 1 `kK `�'�-Q �1� L 1 PARCEL 812E/APNI <br />OWNER'S NAME OhOyl �.t� D;Lg" .�-l3� Kk _ ADDRESS { ((O �.�.t�G'L O}� f i6cjs ovk 9" al b PHONE # Z� JY6 -5-11 + <br />CONTRACTOR F��iVN."�CLa G1Ew'- �+'L✓�'Kv'ti �.K'� q I /Zw4. AOOMOSIDC5 ry� ((Jil�''L �T1Y LX:# PHONE #Z��I G —Ih� <br />RUB CONTRACTOR &V "V-0 go, G v t- _ ADOREBS S 4 "I^"� LN:# PHONE # <br />TYPE OF WELL/PUMP•, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # J <br />❑ N— ❑ R.p.M H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL K <br />ITYPE OF PUMPI`- <br />❑OUT-0FSEFiV10E WFII Cl GEOPHYSICAL WELL / X 80R. BORING i6 9io. b <br />❑ DESTRUCTION? rC 4" <br />+ C <br />FAC/ <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />FEE INFO <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXCAVATION <br />DIA. OF CONDUCTOR CASINO <br />Cl OOMFSTIC/PRIVATE <br />Cl GRAVEL PACK/BrZE <br />TYPE OF CASINOISTEEVPVC <br />OIA. OF WELL CASINO <br />❑ PUBUC/MUNICIPAL <br />❑ DRIVEN <br />DEPTH OF GROUT SEAL <br />SPECIFICATION <br />❑ IRRIGATION/AG <br />❑ OTHER <br />GROUT SEAL 049TALLED BY <br />GROUT BRAND NAME <br />❑ MONITORING <br />GROUT SEAL PUMPED' 11Y.. ClNoCONCRETE <br />PEDESTAL BY DRILLER: Cl Y. Cl No <br />APPROX. DEPTH LOCXINO CHESTER SOX/STOVE PIPE <br />PROPOSED CONSTRUCTtONIDRILLINO METHOD* MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEoEBY CERTIFY THAT 11RAVE PREPARED THIS APPLICATION AND THAT THE WOW WDLL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES. ETA1t LAW". ANU RtvltE -V <br />REGULATIONS OF THE SAN "ADM COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWIIW' "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WMICH <br />THIS PERMIT 18 ISSUED. 1 814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING' ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WINCH THIS PERMIT IS ISSUED. 1 SHALL EMPLOY PERSONS SURJECT TO WORWAAM'S COMPENSATION LAWS OF <br />CALIFORNIA." APPUC VST ALL 24 HOURS IN ADVANCE�! FOR ALL REOUIRIM INSPWTIONN`S AT 12081 4004WZ2. COMPLETE DRANMIO AT LOWER AREA PROVIDED. <br />Shoed X -A- �t-d ✓ Tl"o jI"L Ie'c-� L: Co j vq IQCT O.K. 51 II' Z �l <br />,��tCqc <br />, `K,c�-rK C. lGi N .Yv to Ba.I.I S..1. " to <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUN[M1O THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPA►ISIOH OF SEWAGE DISPOSAL SYSTEMS. <br />7. DIMENSIONED OVTUNF.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN MONS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES. MCLUDINO COVERED AREAS SUCH AS PATIOS, DRIVEWAYS. AND WALKS. ON THE PROPERTY OR ADJO04M PROPERTY. <br />ACCOUNTINO ONLY! <br />AID# <br />FAC/ <br />PE CODES <br />FEE INFO <br />AMOUNT RETMTTED <br />CHECKItCASH RECEIVED SY <br />DAT <br />"EMIT/SERVICE REQUEST NUMBER <br />A90 <br />'.-D wealth Serv. - cnviro. 173 (1/97) <br />INVOICE <br />