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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC IIEALTII SERVICES t-yz)rj <br />ENVIRONMENTAL HEALTH DIVISION <br />/ P.O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br />(209) 4603420 <br />NOR -REFUNDABLE PEAMI_T_EXPIRES 1 YEAR FROM DATE ISSUED <br />(Crmplafe In Trinlient11 -- <br />APPLICATION IS HERE BY MADE TOTIIF SAID JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INS TAIL TIIF WON( DTSCnIBFD. TIII S APPLICATION 16 MADE IN COMPLIANCE WITH SAID <br />JOAQUIN COUNTY DEVELORM�EEfN/TT TITLE, CIIAPTER 9-1 1115..3_AND TIIF STANDARDS Or SAN JOAQUIN COUNTY runLIC 11FAL 111 SFnVICFr, ENVIRONMENTAL HFALTII DIVISION. <br />JOB ADDnESS/On (AAPNI `� "'ti � ,/j k7j _ L¢� ,.ems SIT-I_�L, ^ PARCEL SIZE/AIYJ/ <br />OWiJER'B NAME + LI Zl./ s� ��GG„ ADDRESB_yn ( 1'•IJKI Sj <br />R�CJ�E �' �aV 3 W / ✓6/44" /-N _ ADonFrr by- B NIONE I <br />CONTRACTO <br />�{ <br />S. _ZL�?� PHONE I <br />SVACONTRACTOR AT1nnF66 A.)An <br />tICM PIIONF.I <br />TYPE OF WELL/PUMP: ❑ NEW WELL ❑ nF.PLACFMFNT WFLL ❑ MONUOnINn WFLL R ❑ OTUFR <br />❑ INSTALLATION ❑ WELL SYSTFM nFPAm ❑ Cf1OrS CONNFCT nEPAIR ❑ VAPOR EXTRACTION WELL I <br />❑ New Elrtepo, II.P. DFPTH PUMP SET FT. FInrT WATER LEVEL 0 N <br />HYPE OF PUMP) -- <br />❑ OUT -OF SFRVICF WFIL ❑ OEOI'11YMCAI. WFIL I L�OIL BORING g <br />❑ DESTRUCTION: <br />INTENDED USE TYPE OF WELL-�CONSIRUCIION SPECIFICATIONS- - <br />I r° <br />11 INDUSTRIAL El OPEN RO TTOM DIA. OF WFIL FXCAVATION_ 2.25 DIA. OF CONDUCTOR CASINO p <br />❑ DOMESTIC/MLIVATF ❑ OnAVFL PACK/RIZE TYrr OF CASINO/rTFFI/PVC_ __ DIA. OF Wrt 1. CASINO / D <br />❑ PVBLIC/MUNICIPAL ❑ DRIVEN OFPTII OF GROUT SEAL gj�o SPECIr ICATION—��(7�cjfLfr•--- R <br />❑ InnIOATION/AG ❑ OTNEn GnOIIT SFAI. INRTAI I FD BY T�Af►�I[,�`{^ nnO1rr BRAND NAME F <br />❑ MONITORING OnOUT SFAL PUMIYD: ❑ Yee ❑Lae CONCRETE PEDESTAL BY DRILLER: <br />❑ Y- C� s <br />APPROX. X. DEPTH 7'� I.00KRJO CIIF RTFn flOX/RLOVF. PIPE T <br />PROPOSED CONSTRUCTION/DFUIUNO METHOD: MUD ROTARY AIR nOTAnY AUGFR CABLE OTHFn <br />I HEREBY CERTIFY THAT 1 IIAVE PREPARED THIS APPS-ICATtON AND TIIAT 1HF WOW WILL RF DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY OMINANCF.e, STATE LAWS, AND nUt ES AND <br />REGULATIONS OF TIIE SAN JOAOUIN COUNTY. HOMF OWNER On IJCFNSFD AGrrJT'S SIGNATUnE CFMIFIEr THE FOLLOWING: 'I CFRTIF'Y THAT IN TIIE PERFORMANCE OF TIIE WON( FOR WIIICII <br />11416 PERMIT IS ISSUED, I SIIALL NOT FMPI.OY PERSONS SUBJECT TO WORKMAN'$ COMPFNRATION LAWS OF CAHrORNIA.' CONTRACTOR'S HIRING OR SUR CONTRACTING 61GNATVnr CERTIFIES <br />TUE FOLLOWING: ' I CERTIFY THAT IN THE PFRFOnMANCE OF TIIE WOnK FOR WHICH TIIIS PFnMIT IS ISSUED, I SHALL EMPLOY PEnSONR SI/RJFCT TO WORKMAN -1 COMPENSATION LAWS OF <br />CALIFORNIA.' TOTE APPLICANT MUST CALL 24 <br />HOUR IN ADVANrE FOR ALL nFOUnED INSPECTIONS AT 12091480-3423. COMPLETE DRAWING AT LOWER AREA L`T10VIDED. q <br />planed x p nne%— D.te % <br />PLOT MAN IDS wv to R.,elel <br />1. NAMES OF STREETS On ROADS NFARFST TO On ROUNDING TIIF rnOPFnTY. 4. LOCATION OF IIOl1RF SFWAOE DInPOSAL SYSTFM On PnOPOSED <br />2. OUTLINE OF TIIF MIOPEnTY. OIVINO DIMENSIONS AND NORTH DIRECTION. FXPANSInN OF SEWAGE DISPOSAL SYBTFMB. <br />3. DIMENSIONED OUTLINFB AND LOCATION OF ALL- FXIRTINO AND PFIOPOSFD S. LOCATION Or WFI I.6 WITHIN RADIUS OF ONE tIUNDRFD FIFTY VT. <br />STRUCTL/nEB, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS. AND WALKS. — T1 c I- -..., ... .,... .. <br />Applleellon Aeoopted Sy-1� <br />Groin Irnnecllon By�LC'� <br />DeHnrellen Irnnecllon By <br />Cemrnddc � ! Al Y , <br />DFPAnTMFNT USE ONLY <br />��yPP�Jump In.noollnn By <br />- - M$•- <br />O�- <br />De1n <br />Aree <br />Dete <br />ACCOUNTING ONLY: <br />AIUI jI�FACT <br />PE CODES <br />FEE INFO <br />---------------- <br />AMOUNT REMITTED <br />vu <br />CItECKI/CARII <br />RECEIVED BY <br />DATE <br />PFMAI TI$1'TVICE nEGUERT Nl1MSFTl <br />CJI 1 12 S K <br />G - <br />J .IR <br />INVOICE <br />Pub. Health Serv. - Enviro. 173 (3/96) <br />