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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> J ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468_3420 <br /> i <br /> RON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> APPLICATION IS OfEDE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSPRULCTIATfkp <br /> NDIOR INSTALL THE WDA(DE6CAIBEb.THIS APPLICATION IS MADE IN COMPLIANCE VA'of SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 0-1115-3 AND THE BTANOARDS OF BAN JOAQUIN COUNTY PL UC HEALTH EERVICEB,ENVIRONMENTAL HEALTH DIVISION. <br /> Joe ADDAESSlOR AP111 S S- I:LI C CITY (' 'C <br /> �l /+ •7 PARCEL B2ElAPN/_-I'QO Cj•r <br /> I OWNER'S NAME Yr I' Q 1� / i[`G— A—.. <br /> PHONE <br /> CONTRACTOR] ADDRESS I <br /> PHONE <br /> 5718 CONTRACTOR <br /> ADDRESS RIC/ - <br /> y PHONE/ <br /> I TYPE OF WELL-JMP: ❑WWWELL D REPLACEMENT WELL Q MOWTORIM WELL/ Q OTHER <br /> Q INSTALLATION Q WELL SYSTEM REPAIR Q CROSSCONNECT REPAIR Q VAPOR EXTRACTION WELL <br /> 11 N— J <br /> RVPE OF <br /> IhP�r N.P. DEPTH Pump SET <br /> r STT. FIRST WATER LEVEL O <br /> PUMPt EP�--1I <br /> ❑OUT-OERVICE WELL 4J GEOPHYSICAL WELL/ D BOR SOIONG <br /> XbE6TnUCTION: 6" <br /> K � I ` H <br /> 4 <br /> a Y ✓t <br /> INFENOED USE TYPE OF WELL CONSTRL/CTION SPECIFICATIONS SII <br /> Q INDUSTRIAL QOPEN BOTTOM A <br /> GIA.OT WELL EXCAVATION DIA,OF CONDUCTOR CASINO /`�j'� D <br /> ❑DOMESTICX'RIVATE D GRAVEL PACI[ISRE nPE OF CASINIIIRTEELJFVC DIA.OF WELL CASINO <br /> ❑P1BLN:IMUMCMAL Q DRIVEN '-' D V <br /> (I DEPTH Of GROIfT SEAL 6r-Ecir CATION A <br /> ♦ Q IRISGATIONIAG ❑OTHER GROUT SEAL INET MIED BV GROUT BRAND NAME <br /> Q MONITORINGE <br /> ORO V7 SEAL PVMPEOj Ely- (IN. CONCRETE PEDESTAL BY OWLLER:©Vr ❑NP S <br /> APPROX,DEPTH LOCKING CHESTER eOXISTOVE RPE i <br /> PROPOSED CONSTKUC71OWDRILNNO METHOD:MUD AOTARV AIR ROTARY AUGER CARILEL OTHER S <br /> F I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN JOAGVIN COUNTY ORDINANCES,STATE LAWS,ANO RIRE AHD <br /> REGULATIONS <br /> Of THE SAN JOAOWN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT TN THE ORDINANCES, <br /> N A OF TIRE WOR(FOR WEcHl <br /> A" <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS BUBJECT TO WORKMAN'/COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOT1'B HIRING OR SUB-CONTRACTINO SRINATUDE CERTIIER i <br /> I--t THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF 7HE WORK FOR WHICH THIS ER <br /> S PERMIT 1$IB6VED,1 SHALL EMPLOY PERSONS SVDJECT TO WORIGHAN'S COMPEHRA—N TAWS OF 111 <br /> CAUI`ORMA.- T APPICANT MUST CALL.NO.IN ADVANCE FOR ALL REOU1AED INA ONS AT t20Sl 7AS-7+I .COMPLETE'DRAWING AT LOWER AREA PIOVIMO. [-� <br /> V <br /> BIBn•tl X -•c'iLL <br /> TIO, <br /> / <br /> MOT PLAN(Drew IP%d.)S.-I. <br /> 1, NAMES OF STREET R ROAbb NEAREST TO OR BOUNDINO TIRE%gPE�TTY. S.LOCAMNOF HOUSE SEWAGE DISPOSAL SyBTEM an PROPOSED <br /> 2.OVTHNE OF INE 191OPERn,GMITO OIMENBIONtl AND N.R.DIRECTKIN. EXPANSION OF BEWAOE bAPOeµSYSTEMS. (1♦ <br /> 3.piMFNFM)NEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITTRN RA)Kre OF ONE HUNDRED rim FT. IITt <br /> BTIIUCTVREB,NIOLUOING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAHXS, ON TIG:P1IOPERry OR ADJOINING PROPERTY. <br /> j I <br /> Y <br /> ... <br /> a i ' <br /> 4 . <br /> tvi4 <br /> r ; <br /> Q <br /> 1 ... A <br /> 1]r; f ... <br /> i '® k'..[-T ',f <br /> JUN 23 1997; <br /> SAN AIIiN CCU <br /> _ - - <br /> G M rJ�P�{jrTl,,T�oI' � , .UBIei� rr-I s I r <br /> � OE►ARTMENT VSE ONLY I <br /> k <br /> ApplleMlan Acaepltd BY .' O-- <br /> /i�{/��� '/f �y1 D•S• A,w�C� <br /> G.PW lmpPcllan BY T VL.L/ O•Sa V L P—P N'.PwStm or O•t1 <br /> O.ntntcllen Lw—Ltn DY D•1• <br /> P <br /> Cemme.x•: <br /> E <br /> ACCP UNTINa ONLY: AID/ FACT RIE <br /> PE CODES FEE INFO AMOUNT RENM37ED HEC MASH RECEIVED BY DATE PERMITNERVICY AFOUEST NLANB91 INVOIC4 <br /> I <br /> Pub.Health Serv.-EDviro.173(1/97) <br />