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\PPLICATION FOR WELLIPUMP PERILS <br /> SAti..OAQUIN COUNTY PUBLIC HEALTH SEkVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 ¢y�� Aa <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v/�/� 5j <br /> atel <br /> APPI-(CATION 18 HERE BY MADE TO THE BAN JOAOUMI COUNTY FOR A PERMIT TO CONM <br /> ST RUCTIMJDIORRCINSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADf <br /> I <br /> JOAOUIN COUNTY DEVELOPMENT TILE.CHAPTER 9�-1 11 1 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEAL HT pryl{pN COMPLIANCE WIT,SAN <br /> JOB ADDRESSMA APNO-614� D/TVA 1 //V� S� CITY S PARCEL <br /> �/�� D Q•', / <br /> n BIZE/APNI. V� j� W <br /> OWNER'S NAME p-{ �j / /7 e <br /> 66 / i_R/•RJ C/�!•� PHONE A <br /> CONTRACTOR_. I-Nu/✓� / (� �K �C ! <br /> / ADORE Be (JCI ""ONE,2 07-93�yy(J <br /> RUR CONTRACTOR (,�Y Q <br /> AOLN1E86 tz 66m. Al PHONE <br /> TYPE OF LLPUMP- ❑ NEW WELL ❑ REPLACEMENT WELL MONRORiNG WELL I__.-4— Cl OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ❑N.1:1J <br /> R.v.6r H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> 'TYPE OF PUMP) O <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ SOIL BORING <br /> H <br /> DESTRUCTION- <br /> INTENDED USE TYPE OF WELL <br /> CON{TR11C 7104 SPECIFICATION{ <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM OIA.OF WELL EXCAVATION QUI❑ pIA <br /> / GIA.OF CONDUCTOR CASING �/� D <br /> /MDOMEBTIC/piRIVATE ❑GRAVEL PACK/SIZE 2TYPE OF CASINGlBT EEUPVC ��/` <br /> ❑ PUSUCUNICtPAL El DRIVEN / DIA.OF WFLL CASINO Ol D <br /> DEPTH OF GROUT SEAL ,��jptp ,C�t yo SPECff1CATION <br /> ❑ IRRMATION/AO ❑OTHER R <br /> GROUT REAL INSTALLED 8Y N Ice- <br /> MONITORING GROUT BRAND NAME <br /> X� Ky E <br /> I GROUT SEAL PUMPED: ClV« Ne CONCRETE PEDESTAL BY DAILLM Lal Y— ❑Ne <br /> APPROX.DEPTH S <br /> LOCKING CHESTER SOX/STOVE PIPE jI�)C <br /> AtOPORED CON6TRUCT10"I/LLINQ METHOD: MUD ROTARYS <br /> AiR ROTARY AUGER�_CASTE OTHER <br /> 114E4ESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WR-L BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AHO RULES AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMrT t6 ISSUED.I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-6 COMPENSATION LAWS OF CALFFOFMA.' CONTRACTOR'S MPoNO OR SVSCONi11ACTINO SIGNATURE CERTIFlES <br /> THE FOLLOWING: •1 CERTIFY THAT IN TIRE PERFORMANCE OF THE WONL FOR WHICH THIS PERM T IS ISSUED,I SHALL EMPLOY PERSONS BRING TO WO ONTR'6 LNG SIGNATURE LAWS fS <br /> CALIFORMA.' T A A HOUR{IN ADVANCE FOR ALL REGL/111ED INSp%CT/ONNSS AT 12061 468.$42222.. COMPLETE DMWINO AT LOWER AREA PROVIDED. OF <br /> TIOSlon.d x CTILL. �j�,/'�/<O�ff <br /> ROi RAN 10rtwv to Se.N1 Se.N to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUND040 THE PROPERTY. <br /> 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. 4- LOCATION OF HOUSE SEWAGE IHSiOSAL SYSTEM OR PROPOSED <br /> ]. DIAfIENSIOWD OUTUNF.B AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEM6. <br /> STRUCTU EB.INCLUDpM COVE,"AREAS SUCH A8 PATP08.ONVIEWAYS.AND WALK8. 8. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOpnNG PROPERTY. <br /> li <br /> DWARTMENT USE ONLY <br /> A..4..t;—A.eeet.d Br D.h /0—/� G / Ar« C / <br /> Moan Inueeeele..er O.n L Pl.rq Ir+oe.tbn By D.t. <br /> O...vuetbn Ir.w..etien By /,/ ✓ * D.t. ���/� <br /> Co.nment. '"� � 7LJ'L.•C <br /> ACCOUNTING ONLY: AID( FAC! <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK)/lCASH RECEIVED By DATE PLBNAIT/8grACE REQUEST NUMBER INVOICE <br /> Pub.Health Serv.-Ertviro. 173(1/97) <br />