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LIAR 2 91990 APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, <br />ENVIRONMENTAL HEALTH DIVISION '' �I" <br />,,,;k <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 MAR 17 1999 <br />(209) 468-3420 _ <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED —1`JV�1,f.ylsiJ'C��!l��a�—�.L.Tj'J <br />(Complete In TripRevtE) PFR�,QIT <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WR11 SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTYPUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB AOORESS/OR&1' <br />IDr' j CITY J / 1: c T PARCEL 912E/APN! <br />OWNER'S NAME�r-,•� ((ii�i--,,��w/ 1I W/ I R DT11 ADDRESS [�, ,^U QC, v 0 I C 1 PHONE !7 YC.Z LCONTRACTOR \ `^'it t�(re . l+ i t ADD/1E99 7 LL � A. t,,, �p y�`! ( T. U %" J'V uI <br />S„ I�i eV� 7 NC! 1(,'� G L27 <br />PUB CONTRACTOR ADDRESS UG PHONE! <br />TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELLMONITORING WELL ! I1'f ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL ! <br />11New ElRepalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (� <br />(TYPE OF PVMPI �J�.. <br />❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL ! ❑ SOIL BORING e �y <br />❑ DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />❑ INDUSTRIAL ������❑17] OPEN BOTTOM 2 ^ DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING � O <br />❑ DOMESTICIMVATE �aRAVEL PACK/SRF_ -J 51�ye'_/ TYPE OF CASINO/6TEEL/PVC I �i� 1 DIA. OF WELL CASINO ' 1L ) 11C (, D <br />❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL ' ,�1,_'} T� 1 J �P� r SPECIFICATION SC Dryp(i�e �(Z 7n,(,� R <br />j❑ I�RHIOAT KTN/AO ❑OTHER ORotTT SEAL INSTALLED BY R Pori k II%1' )�'{i-0 GROUT BRAND NAME? (, i J� AIV E � <br />jd�MONITORINO Z ( l t GROUT SEAL PUMPED: Ys ❑ Ne CONCRETE PEDESTAL BY DRILLER: Jy Y« CIN. S (� <br />APPROX. X. DEPTH �S �Z G'T t� J C^+ LOCKING CHESTER 80 STO PIPE L ( \ ��y--- <br />PROPOSED CONSTRUCTION/DPoWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />1 HE9EBY 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 SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF TIIE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTINO SIGNATURE CERTIFIES <br />THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of <br />CAUFORNIA.' HE APPLICANT MUST CALL 24 I}_O IN ADVANCE FOR ALL REQUIRED IN T10N8 AT 12tH) A�SJI-2'`7. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />9lprxd X I/')� <br />'J TINSG\l�( ' J-+����(J <br />PLOT PLAN (Drew. to Soelel Seale ' to <br />1. NAMES OF STREETS OR ROAD NEAREST TO OR BOUNDING THE PROPERTY. !. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EX19TWO AND PROPOSED f. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AB PATIOS, DRIVEWAYS, AND WALK8. ON THE PROPERTY OR ADJOINING PROPERTY. <br />....;....... ..t.... ... <br />vff <br />dt �J <br />fprpvo <br />. . .-- <br />Applle.11ort Aeeepled By <br />O—A IMP -0— By <br />O.etviwtlen Impeett. By <br />USE ONLY <br />Imp Imp..tbn <br />2Z4" <br />bHe MM <br />Det. <br />ACCOUNTING ONLY: <br />AID! <br />FAC! <br />PE CODES <br />FEE INFO AMOUNT REMITTED CHECK!/CASH <br />R CEI !O BCr / DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />411 <br />-7 <br />Pub Health Serv. - Enviro. 173 (1/97) <br />