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APPLICATION FOR WELLIPUMP PERMIT USAN JOAQUIN COUNTY PUBLIC HEALTH SEBVHRB/ ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4683420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION IS HERE BY MADE TO THE BAN JOAMIN COUNTY FOR A PERMIT TO CONSTI RUCTAMMITI INSBTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER B-1116.3 AND THE STANDARDS OF BAN JOAOUIH COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMIMAL/.•1 JOB ADOPo:SSOR A,H,2 S/7f (ou�n�/tr�y/�Uu/�b � �.rL_ CITY��(J[k.T reyL .L� PARCEL SIZEJAM,�/py[J�Llrt OWNER'S NAME_,][ f(I1D.lI PFEK•{H,yJ (D ADDRESS PID,/1RnDY � �J' /T•� Z RpNE'99O CONTRACTOR CNV/ I VE.S i TY))C.. ADDRESS �E/147/O EC 1 ,�A�LE!�L1CI PHONE IZOAVL"y1S)��ISpr�II PVBCONTMCTOR9_dY'I IIIKG ADOMRS YS(7 �fnWG E(EAFNrIICIY�57L5r PNONEIryD'31J JDP/IJ TYPE OF WELVPUMP: yy NEW WELL ❑ REMCEMEM WELL pl MONITORING WELL Iyg I2w-13 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EKTMCTON WELL I J ❑New❑Repelr N.P. DEPTH PUMP SETFT. FIRST WATER LEVEL RYPE OF PUMP) O 11OUT-OT-SERVICE WELL 11 (IMPHYSICAL WELL R ❑ 80D BORING R ❑DESTRUCTION INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS L1INDUSTRIAL 11 OPEN OF WELL EXCAVATION I9 OPEN BOTTOM JY DIA.OF CONDUCTOR CASINO �Q JS O ❑ IOMEetICR'RIVATE 03 GRAVEL PACKIBRETYP'f OF CARINO/STEEINVC PVC. DIA.OF WELL CASING GPY ❑ PUBLICRAUNICIPAL 11DRIVEN SA DEPTH OF GROUT BEAL 30 Y SPECIFICATION 7 R ❑ IMIGATIONIAG 11OTHER GROVE BEAL INSTALLED BY DV I� Y.Y. SMUT BRAND NAME E MD9ONITORING GROUT SEAL PUMPED: ❑ Ip Y. Ne CONCRETE PEDESTAL BY DNLLER:I��U Yr ❑N. S APPRO%.DEPTH LOCKING CHESTER BOEIStOVE PIP, S PIOPUSED COMBTSM"ONIMDLUNO METHOD: MND ROTARY AIR ROTARY AMERY _CABLE OTHER I HERFRY CEIDIFY THAT 1 HAVE PREPARE.THIS APPLICATION ANO THAT THE WOR(WILL BE DONE M ACCORDANCE MATH BAN JOAQUIN COUNTY OSDINANCFB.STATE LAWS,AND BVLEB AND REGULATIONS OF THE BAN JOAOGIN COUNTY, HOME W,,Fn OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'R CERTIFY THAT IN THE PERFORMANCE OF THE MW FOR WHICH THIS PRMIT M ISSUED,1 SHALL NOT EMKOYMAR NS SUBJECT TO WORKMAN'S COMPFNBAbON UWB OF CALIFORNIA.' CONTMCTOR'S HIMNG OR MWCONTRACTING BONATURE CERTIFIES THEFOLUO RK FOR WHICH TH19 PERMILIT CALIFORNIA CAN I PIIC N THAT TII 41 VIS PERFORMANCE ADVANCE FOR ALL RECURRM INSSPECTION�MISSUED,DRAS R S�N�I'MPUOY PERSONS SUBJECT TO WORKSHOPS COM/K"E�O,MMANO AT LOWER AREA PROVIDED. "We OF BIVrd% (; �� /' .4,-1� TRI. PLOT PUN IOrwv m Sar.l S .la •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR POIOSFD Z. OUTLINE OF THE PROPERTY.DIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE DISPOSAL SYSTEMS. T DIMENSIONED OUTLINER ANO LOCATION OF ALL EXISTING AND PTOPOSM S. LOCATION N OF WELLS WITHIN SAL S T ONE NVNOREO FIFTY R. STRUCTURES,INCLUDING COVERED AREAS SVC"AS PATIOS,DPoVEWAVS,AND WAl%e. ON THE PROPERTY OR ADJOINING FBOPLRTY. ST Map RHv ' DEPARTMENT USE ONLY AppIb.11en Ae.eplex By / • 1�' 1 \ 1�, `O. ON'Ut P. Il BY Dna P p In.Pmtlen By 1147 CNA. Oabveeen Imn«Ilea By D.le Comm>x.: ACCOUNTING ONLY: AIDS FAC/ PE COD" FEE INFO AMOUNT REMITTED CMCKPMASH RECEIVED BY DATE (NEMA TISERVICE REQUEST NUMBER INVOICE 0 $ b139I Pub.Health Sew.-Envim,173(3/96)