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.� APPLICATION FOR WELLIPUMP PERMIT *400 <br /> SAN JOAQUIN COUNvL-PUR[r3 HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PXX BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (los) 469.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (ComplRb In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY <br /> /PUBLIC 14FALT14 SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNf(18 6 5-`146 7 Coapt,try club Slid CITI��(10,,��(/�A� _PARCEL RI2E/AFRI/ 113-014A—/7 <br /> OWNER'S NAME ■7yQ��A�y�Ut� * W*/� r ADDRESS'450 L teedyI, ,( gA%AtA - (peck- PHONE <br /> CONTRACTOR_ EhV i YbsiTl C. ADDRESS�@O/goxavr9 so►�awta UC,I PHONE 17o 7-93S-ys�a <br /> RVB CONTRACTOR V 7 W Q Dr;11 l�tg <br /> O ADOnFR6 ICE ��PHONE m <br /> d <br /> TYPE OF WELLIPUMP: ❑ NFW WELL ❑ REPLACEMENT WELL ❑ MONR ORINO WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL.1 _ <br /> ❑New 11m <br /> R .lr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> HYPE OF PUMP) / p <br /> ❑ OIIT-Or.SERVICE WELL El GEOPHYSICAL <br /> GEOPHYSICAL WELL 2 BOIL BORING .J <br /> ❑OFSTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONe - A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CARING O <br /> ❑ DOMFSTIC/PRIVATE ❑GRAVEL PACK/RI7E TYPE OF CARING/STEFIJPVC DIA.OF WFLL CASINO <br /> ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROAT SEAL SPECIFICATION p <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SFAL INSTALLED BY GROUT BRAND NAME f <br /> MONITORING GROUT SEAL PUMPED: [I Y- (IN. CONCIIETE PEDESTAL BY DRILLFR:❑Y- N. S <br /> APPROX. DEPTH LOCKING CHFSTER BOX/STOVE PIPE 5 <br /> PROPOSED CONeTRI/CTIONfIWtUNG METHOD: MUD ROTARY AIR AOTARY X AUGER CABLE OTHER <br /> I RF'"Y CERTIFY THAT 1 HAVE PREPARED THtR APPUCATION AND THAT THE V40W WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OnnINANCEB,RTATE LAWS,AND RULER ANO <br /> RFOULATIONS Of THE SAN JOAQUIN COUNTY, HOME OWWFR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> TIRA PERMIT IS ISSUED,I SHAI L NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN TIIE PERFORMANCE OF THF WORK FOR WHICH THIS PERMrr IS IRSUED,1 SHALL EMPLOY PERSONA SURJFCT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOtARED INSPECTIONS AT 12061 4ee-242J. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> RI,r,.a x �i'DjCr-1` Geo/agls7' D.tn �-rytar-�7 <br /> Tltl. <br /> PLOT Pll1N 14r.w to Be Mel SP.Is le <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF 1/OUSE SEWAGE DISPOSAL SYSTEM On Pm)rosED <br /> 2. OLITLINP OF THE PnOPFRTY,GIVING DIMFNBIONS AND NORTH DIRFCTKTN. EXPANSION OF SEWAGE DISPOSAL SYSTFMB. <br /> 2. DI#MNRKINED OVTLIWR AND LOCATION OF ALL FXIRTING AND PROPOSED S. LOCATION OF WFLLS WrTMN RADIUR OF ONE HUNDRED FIFTY FT. <br /> STRUCTURE$.INCLLIDING COVERED ARF.AB SUCH AS PATIOS.DRIVEWAYS,AND WALKR. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 1 <br /> DEPARTMENT USE ONLY ^ <br /> ApP1le.tlnn AceeOletl ByDete A­ <br /> Growl In.pmtion BY Dete Pump In.Pmtlen By O.te <br /> L>e.tnralMn Impmllen By p '.-1 D.t. <br /> ACCOUNTING ONLY: AID! FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKNICASH RECEIVED By DATEPERMITIeERVICE REQUEST NIXNBER INVOICE <br /> 0-6 <br /> Pub.Heakh Serv.-Enviro.173(3/96) <br />