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APPLICATION FOR WELLIPUMP PERMIT <br /> USAN JOAOUIN COUNTY PUBLIC HEALTH SERVI&W <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388 904 EAST WEBER AVENUE, STOCKTON. CA 95201388 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In TrlpRedB) <br /> APPLICATION IS HEM BY MADE TO THE BAN JOAOOIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WELL SAN <br /> "AWN COUNTY DEVELOPMENT TRUE <br /> E..CHAPTER 9-111/6..3 AM THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODIESSAIR/AAM' 0161�7�j CO 1([E'IIyI�I N/ CALL /DL �/1 Rly d CITY �/ptkL . PARCELSIZEIAPN/ <br /> OWNER'S NAME \ iGI I I TQ,V�] � .7 E LA4'C_(lf C-YT ADDRESS P O Box ao 4A r rpa-ror► FHONE Q69-9Ys-3 4. <br /> CONT CTOR AO. L,J/Y�I II--pp�YLG�� AODFo8S gn.SD lfrHA z U`Cff 95/f5 PHONE/ 3 O--fif o <br /> BUB CONTRACTOR `PLV PrOSI LVI-Ci ADO11E86 y`o18oX D2.59t I/C/ PHONE/JDI'y3S�'�/as'y <br /> TYPE OF WELLIPUMP: Iq NEW WELL ❑ RFPLACEMFNI WELL ❑ MONITORING WELL SMW 4 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM PFPAIn ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTMCTION WELL F J <br /> ❑N—❑R .I, HP. DEPTH RUMP SET_FT. FIRST WATER LEVEL 0 <br /> HYPE OF PUMP) <br /> 11 OUT OF SERVICE WELL ❑ OEORIYSICAL WELL/ ❑ SOIL ROGINO B <br /> ❑DESTRUCTION' <br /> INTENDED USE TYPE OF WELL CONSTAM71ON SPECIFICATIONS IE A <br /> 11 INDUSTRIAL 11 OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO NT D <br /> ❑ DOMESTIC"IVATE �L/j--A�.GRAVEL PACKISIZE 3LaRr,_ TYPE OF CASINAISTEELJPVC INA.OF WELL CASING (yTE D <br /> 11U <br /> PUBC"UNICIPAL LJDRIVEN DEPINGFOROUTSEAL D-14' SE4CIFICATION DC1 go B <br /> -P❑ IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY Dri(Ia' O,MT BMW NAME Il,X�/E E <br /> MONITORING OPIUM SEAL PUMPED: [IYw 0N CONCRETE PEDESTAL BY DRILLER:LO Y� ❑Ne S <br /> APPROX.DEPTH LOCKING CHESTER BOXIBTOVE RPE S <br /> PROPOSED CONSTRUCTDNmISLVNO METHOD: MUD ROTARY AIR ROTARY AUGER---v _CABLE OTHER <br /> 111E9ERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOn(WILL BE DONE IN ACCORDANCE VATH BAN JOAOUIN COVNTY ORDINANCES,STATE LAWS,AND RULER AND <br /> REGULATIONS OF THE BAN"AMIN COUNTY. HOME OWNER OR LICENSED MENT'B SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE FERFORMANCE OF THE WORK FOR WHICH <br /> 11118 PERMIT IB ISSUED,I SHALL NOT EMPLOYFERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTMCTOOS HIRINO OR BUE.CONTMCTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS KRMM IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORXi COMPENUIION"WOOF <br /> CALIFORNIA.- We APPLICANT MUST CALL ZA MOVRS IN ADVANCE FOR ALL MIMMI��NS t AIA ft NO�22 COMPLETE DMWIAT LOWER AREA PEK)VIDEO. <br /> BlP^b x TPR. TF E Wll<r'iGf% e_ /= (F -/,I <br /> 7 <br /> v IfD.I. i <br /> PLOT RAN 101.le Seelel Steele •le <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On POTSEO <br /> Z. OUTLINE OF THE PEOPEATY,OMNO DIMENSIONS AND NORTH DIRECTION. EMS. <br /> DISPOSAL SYSDISPT <br /> EXPANSION OF SEWAGE <br /> G. DIMENSIONED OUTLINES AND LOCATION OF ALL EMITTING ANO PROPOSED S. LOCATION OF WELLS E DISPTHIN RADIUS T ONE HUNDRED FIFTY R. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PRDPEDOC <br /> DEPARTMENT USE ONLY � � <br /> APFlbelbn Ae Nd De <br /> By�-`,/�� <br /> F U <br /> Grevl Iepeelbn BY OKe Pump Impxtlen BY Del. <br /> OMRlnlbp In,pmllen BY <br /> Gels <br /> Cemmep.: l'al�lci�s ttnrr r wwnt 4--rPnit 109q-65V- -D3&1 ba <br /> N r iuc w _ PM _. <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE IWO UNT REMITTED CHECKIMASH RECEIVED SY DATE FEIMIIT/eFAVICE REQUEST NUHSER INVOICE <br /> 64IWZ 9.31 <br /> Pub.Health Saw.-Enviro.173(3/96) <br />