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PAYMENT <br />ITEC 0 8 1998 <br />APPLICATION FOR WEWPUMP 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 />YtJre 1C` 7lEE',LTH ScRViCES <br />O ml MNJs <br />✓oGzii <br />ORIGINAL <br />AL HEALTH DIVISI%A NOM -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Tripliestal <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 8-1 115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY <br />%PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESSOR APNI , - Ova CI�TfY jj / / (1 �� ^PARCEL 91ZE/AR`Nl <br />OWNER'S NAME/� �, I /' CC 1j j A Ur ADDRESS `26 1 (�c'J-.,T+f -�e81 vrte• PHONE f <br />CONTRACTOR /'A1j,-jN 10 11• P d `�n V /t'u:'lA1 iv J r9 1 'LSC , ADDRESS y(JC,-S JV • Ih„ 1S/���1 �'V'/ / ucF /v 1 PHONE L LA <br />SUB CONTRACTOR ADORESS UC! PHONE <br />TYPE OF WELL/PUMP: NEW WELL <br />`f❑``INSTALLATION <br />❑ New ❑ P.,.I, <br />HYPE OF PUMP) <br />❑ DESTRUCTION: <br />❑ REPLACEMENT WELLMONRORING WELL 1 U! r. M W L ❑ OTHER <br />❑ WELL SYSTEM REPAIR CRO88-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ,/ <br />H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 'k- 15 • %1S C'� O <br />11OUT-OF-SERVICEWELL 11 GEOPHYSICAL WELL / 11 SOIL BORING "� <br />❑ INDUSTRIAL ❑ OPEN BOTTOM �J <br />❑ <br />DOMESTIC/PRIVATE GRAVEL PACK/SIZE � 7 <br />❑ PUBLIC/MUNIC IPAL tDRIVEN <br />❑ IRRIGATION/AG ❑ OTHER <br />AMONITORING n / <br />// APPROX. DEPTH J L <br />PROPOSED CONS TRUCTIO N/DNU1NO METHOD: MUD ROTARY <br />B <br />cvn 1-11un orewrlcANuAn■ A <br />DIA. OF WELL EXCAVATION ".�(�,� / l,� DIA. OF CONDUCTOR CASINO <br />TYPE OF CASINO/STEEL/PVC DIA. OF WELL CASINO ^ Irl( t 0 <br />_11 r - <br />DEPTH OF GROUT SEAL Jy , ,AL T4 !�✓p SPECIFICATION J o'R <br />GROUT SEAL INSTALLED BY � � !Yl l� rI k TSV 0 D GROUT BRAND NAME ". vE <br />GROUT SEAL PUMPED: Ys ❑ No LC K;,l CONCRETE PEDESTAL BY DRILLER Yee ❑ No S <br />Z <br />LOCKING CHESTER BOX/BTO PE 41r�'-' S <br />AIR ROTARY AUGER CABLE OTHER <br />I HE-ZRY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-$ COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS -CONTRACTING SIGNATURE CERTIFIES <br />TETE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORIWAN'S COMPENSATION LAWS OF <br />CAUFORNIA.- TV APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED t►ECTRON� AT 12M1 4p-1427. COMPLETE DRAWING AT LOWER AREA //P//R��OVIIDED. <br />819—d X Tltl. ♦I�\ '(4 '1% / D.ta /L r J , <br />PLOT PLAN (D.ew to Salol Seel. ' to <br />1. NAMES OF STREETS OR ROAD NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR F410POSED <br />2. OUTLINE OF THE PROPERTY, OIVMq DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTWO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDINO COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />ApPlloetlon Aeeepted By <br />Oreut I. Pocllon By <br />Do.ln+ctlon In.Peetbn <br />Comm—f n <br />DEPAATMENT USE ONLY <br />Oet. Pump t—p—tion By <br />a dI" <br />ACCOUNTING ONLY: I AID/ I FAC/ <br />D.q. 12 SI/1044r, <br />PE CODES I FEE INFO I AMOUNT REMITTED L CHECK/!CASH I RECEIVED BY I DATE --"0v IT/SERVICE-1EGtl!¢L.IarAtER I INVOICE <br />