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APPLICATION FOR WELL/PUMP PERMIT S��a <br />`� �.�. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />E0,E ;3 -:El 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />AUG 2 5 1998 (209) 468-3420 <br />FOUR -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SAN .IU/'.(1t,)!tJ UOUN I f (Complete ie Tr(plkatel <br />APF'LICATIOFjTR j{€rg filt JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. T1113 APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOVIMf�tD✓fi�id(mEV'E[IgP_T'�EF�ILTFFi ;CI+SirER 9-1115.3 AND THE STANDARDS <br />� OF USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESSOR APN# � .10'L'�, V` S�'tM� <br />p`CITYIZ�✓ C���C... '''�-�1,,,AAA• '1"-'`�S `I/'� j S1 PARCEL 81ZE/APNI <br />OWNER'SNAME <br />�q <br />ADDRESS 10 'Z�Ci ;�8C-�5 <br />CONTRACTOR Ai,V Cr_ -%� [wL• AODRfS9 UCO PHONE / 7-ZC <br />-1 <br />SUBCONTRACTOR V",UV � tpTik \:4 ADDRESSkjS"51, Kai UCO PHONE 12073N , b f <br />N <br />TYPE OF WELL/PUMP: WNEW WELL ❑ REPLACEMENT WELL WM()NrTOPJNO WELL # I ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # J <br />❑ New ❑ Repdr H.P, DEPTH PUMP SET FT. FIRST WATER LEVEL O <br />(TYPE OF PUMPI <br />❑ OUT -0F -SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING g <br />❑ DESTRUCTION: <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />W s <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXCAVATION l; <br />MIA p <br />DIA. OF CONDUCTOR CASINO N( W <br />❑ DOMESTIC/PRIVATE <br />❑ GRAVEL PACK/SIZE <br />TYPE OF CASINO/STEFLIPVC L <br />DIA. OF WELL CASING Z <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN <br />DEPTH OF GROUT SEAL t <br />SPECIFICATION Sc� - Li` <br />IRRIGATION/AO <br />❑ OTHER <br />GROUT SEAL INSTALLED BY �'f'e•A^t 't- <br />OROUT BRAND NAME wX,+Li[J+ttIL-/ Cr-vN/`� <br />j❑ <br />3, MONITORINO <br />t,[IN. <br />GROUT SEAL PUMPED: ❑ Yee ❑ Ne <br />CONCRETE PEDESTAL BY DRILLER: ❑ Yee ❑ No <br />APPROX. DEPTH ( v Vt—lr LOCKING CHESTER SOX/STOVE PIPE' <br />PROPOSED CONSTRUCTIONMIILLINO METHOD: MUD ROTARY AIR ROTARY AUGER ,X CABLE OTHER <br />1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE BAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />T1419 PERMIT IS ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRINO OR BUB -CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMTF 18 ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORMAA..' THE APPUC ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INS►EC TICNG /AT 1200011/448-2422. COMPLETE DRAWING AT LOWER AREA PROVIDED. (�+ <br />Signed X,I�L'VL�� Title ^ (,L/i'l.G.-✓\ / / 111�Y1,G� �i/�� Dets •7 / �1 r'L ,] <br />l PLOT PLAN "— to Scale) Bode ' 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, OIV1N0 DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, lvxJ\ <br />3. DIMENSIONED OLRLINFS AND LOCATION OF ALL EXISTWO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS. DRIVEWAYS_ ANO WAt If <br />z <br />i <br />PE CODES <br />W s <br />AMOUNT REMITTED <br />o w Lil Q <br />o <br />0v <br />INVOICE <br />w Q U Z <br />z z <br />..z <br />4S ( co <br />z m Q O <br />�40r <br />i <br />Q F- O LL <br />Q W 0 J o 0 J <br />O Q <br />U <br />d W w Li U <br />7 <br />r ft� <br />W d W Z W w - <br />_ LL Z <br />n V, 0O aO <br />m N <br />�n0 m 0 <br />W Y J 1- <br />w U `1 <br />U) W <br />_ O In U <br />o N w O <br />z, <br />L0 �J <br />n w V) <br />r <br />NQ 0� <br />N <br />Z <br />C) <br />o <br />F <br />Q <br />O <br />¢ <br />W O <br />z <br />O <br />J <br />z <br />Li <br />p <br />O) <br />W O <br />Z <br />O Z <br />2 <br />af <br />9 <br />o z <br />� <br />O <br />z_ <br />0 <br />w <br />O to <br />m O <br />d <br />J w <br />o tr <br />� d <br />z <br />W <br />0 <br />W <br />J <br />£V-S£L-L6 <br />N <br />oNIMV8IMraG <br />DEPMTMENT USE ONLY <br />Applloetlon Aeeepled BY, 1�\.\CJVI '��V �F�Vr� Ode Z My <br />0,.Ut HNpeeUen BY 1l`. \.\;�'V'�L �-:: Dete 4 iv(Ct RmP IneP-tlon BY Date <br />OMtnwtlon Impaction BY Date <br />ACCOUNTING ONLY: AID# FACS <br />11e_wi <br />i <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK#/CASH RECEIVED BY DATk <br />PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />SIS <br />4S ( co <br />S' - <br />Pub Health Serv. - Enviro. 173 (1/97) <br />