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11—©S-1997 1:SSPM 1=ROM P-2 <br />APPLICATION FOR WELL./PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />ROA -RE RRDABLE PERMIT EXPIRES 1 TEAR FROM DATE ISStI <br />Mampleft Is Trfp6etltl <br />APPLICATION t6 HERE BY &9ADE TO THE SAN JOA40IN COUNTY FSR A Pc AALT TO CONSTRUCT ANDJOR INVALL THE WORK OESCRRBED. TPR16 APPLICATION B MADE IN COSAPLIAHCE WITH SAN <br />JOAOUIM COUNTY DEVELOPMENT TM -F- CHAPTER 9-1 116-3 AND THE GTANOAROB OF SAN JOA<X)W COUNTY PU9lJC HEALTH 9CRLACM EW.14UNAMEMnE WALTIA Or m am - <br />AlOf FACT <br />PS coo" <br />JOB AOORESSJDR APNI <br />- C. c ✓7 CITY L �j <br />PARCEL 817FJAFTI, <br />aw14ER B NAr1E v <br />C_ pi) � <br />�S8t L -C)(SS <br />1 !� <br />CONTRACTOR-� ,�- la c. l7 u.n/c l i-nr_ AoalEe.` �IZ fz.>11.7 P`.<- park <br />prucf. LL -A/9`' PHONE I, <br />• <br />eve CONTRACTC- �--LLjG e- <br />I I ( I ). ADORt6W 2- (L FI <br />1f 1 ri _ Z / 1 ! L!.!.' . IG( <br />1 <br />P LC f PNOIIF f / i '� •-' i <br />Iz '6 �DoZZ7 q <br />c <br />=OF WET,IJf'L1MP, ❑ NEW WELL <br />O REPLACEMENT wra IJ WTORINO wFu I (nom i h, <br />❑ 0T71ER <br />❑ INSTALLATION <br />p wtu evSTrm REPAIR ❑ CROR&CTNOgCT REPAIR <br />Cl VAPOR EXTRACTION WELL f J <br />❑ N— ❑ R.P.ir <br />N P. DEPTH Pvw RET FT, <br />FIRST WATER LEVEL 0 <br />(I YPE OF PUI.frl) <br />❑ OUT4F-tEfw cE WELL ❑ GEOPHV9cAL WELL r <br />❑ ROIL SOMNG e <br />❑ DECIRvcrloN; <br />INTENDED UAC TVD{ Qf WELL <br />CONATRUCTION 1PECTiCATR0Nt <br />A <br />❑ 11OVSTIUAL ❑ OPEN 60TTOM <br />G <br />DIA. Of WELL EXCAVATION p Vl <br />DtA. OF CoNOUCTOR CASINO O <br />❑ OOIIERTI--/P VATS ❑ GRAVEL PACKIBTIE <br />I/ <br />TYPE OF CAR*nMTC"j9%-C V <br />ORA, OF M/ElL CASINO Yi D <br />❑ 0,16LICAIUMCI'AL ❑ 0MVEN <br />/ <br />OEMN OF GROUT SEAL/ 5 Sf? I . �J �,� `!S l7) <br />SPECIFICATION R <br />❑ R"t<RRGATROWAW ❑ OTHER <br />GMUT ZEAL PISTALiID BY <br />GROUT 6RAND NAME E <br />LQ IAONJTOJHNO <br />GROUT SEAL IVMPEOe ❑ Yr Cl N. <br />CONCRETE PEDESTAL SY DR0u m ❑ Yw ❑ N. <br />APPROX. DWT14 <br />LOCKING CHESTERPIPE <br />s <br />/18OXJBTOVE <br />I <br />PROPOIIED C0N2TR(JCTTOF4MWLUXl2 &9671400: <br />MUD ROTARY AIR ROTARY ---A1l(;lR <br />OTHER <br />I HE-WIY CERTIFY THAT I HAVE PREPARED TMS APPOCAT/ON AMD THAT THE WORK WILL BE DOW M ACCORDANCE WITH BAN JOAOUIN COUNTY ORDtNAHCEB. STATE IAWS. AND RULER AN0 <br />MGULATIONS O: THE SAN JOAOVM COUNTY, HOME OWNER OR L)CENBED AGENT'S SIGNATURE CERTIFIEU THE FOUMOANO: 'I CERT6Y THAT IN THE PtIVORIAANCE OF THE WORK FOA WHICH <br />THIR cEAJ.;TT fS I1781JED, 1 RHALL NOT EIATSOY PERSON'S 6U6JECT TO WORgMAN'f CO&9P4NtAT10R LAWS OF CAEFORFSA.� CONTRACTOR -8 HI11NO OR 4U6 -CONTRACTING (TGHATVRE CE:ITOWS <br />THE VOLLOWING: ' I CERTIFY THAT IN TTIE KPOFO-VANCE OF THE woft( FOR WNICH TWO PERLIRT t61eelJED. 104ALL EMPLOY PERSONS VJRJECT TO WORIDAAR-t CosammtAT10N LAMM of <br />CA4j[Oro+JA�-J1PotJCAfIT MVRf,T C taoRAu IN AnVANt'6 Sow ALL RFOLARED NIi►4tt1vR.7 AT CIO.t COUP1ETg OMWtNG AT LOW" AsEA FsgVTDEO. <br />T.I. <br />PLOT PLAN 0- 1. S..W S.W. ' I. <br />I. NA&9E8 Of 9TREET6 OR ROADS NEAREST TO OR OOUPAYM THE PHOITRTY- A. LOCATION OF HOUSE SEWAGE. OISPOSAL SYSTEM OR PROP06ED <br />2. OUTLHE OF THE PROPERTY- OLVIMO OVALN9 0" ANO NOIRT" DIRECTION. EXPANSION Of KWAOE DISPOSAL SYSTEUS- <br />7. ORI•IEN®OMED OtrFVWF,S AND LOCATIC" Of ALL EXISTTNO AND PROWSED 6. LOCATION OF WELLS WITHIN RAOIUS Of ONE WJNClWD FIFTY FT. <br />STRUCTURES,. UICLUOING COVOIZO AFE,.B SUCH AS PATIOS, DTVvEWAYS, ANO WALKS. ON THE' PYOPERTY OR ADJOINING PAOPERTY, <br />A N ` JNC A <br />....... .............. <br />(L—A 4+..e"— <br />DBARTIAENT 1066 ONLT <br />D.. ('/ 2I / CYC P's <br />ACCOUKTINO ONLYt <br />AlOf FACT <br />PS coo" <br />FEE WPO <br />AMOUNT REMITTED <br />CHECKSICASH <br />REC6VED 6T <br />OATIE Ismvv F pecu T <br />IfIVOICI <br />oa z' <br />Iz '6 �DoZZ7 q <br />Pub. Heats Sem - Enviro. 173 (1197) <br />