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►PPLICATION FOR WELLIPUNI PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC,HFH SERVICES <br /> ' NVIRONMENTAL HEALTH SIGN <br /> 304 EAST WEBER AVENUE,STOCKTOCA 95202 <br /> (209)468-3420 <br /> RON�FIIRPARLE PERMITEXPIRES 1 YEAR FROIM d ? 183UI ll <br /> �t (Complete In TrlpReal,i <br /> I APPLICATION IS HERE BY MADE TO THE BAN JOAOUIP COlR1TY FORA' PERMIT TO CONSTRUCT ANDIOR INSTALLAMD1CRIBED.THIS A vCAMN IS MADE IN COMPLIANCE WITH SAM <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 91111115:3 AND THE,TANDMq]S OF SAN JOAOUIN COtyNTY SERVICES.ENVOONMENTAL HEALTH DIVISION. <br /> �CJOB ADORESSIOR APR/ b "A L � �� rry PARCEL SIZE/APv7 <br /> eig <br /> OWNERS NAME �i�-C�_ i�-��'2" 1( _-- _ ADDRESS �x'�� PHONE 4„ �C L1 <br /> CONTRACTOR 0,-,v ADDRESS 4�[,I R10HE,t <br /> I <br /> ave CONTRACTOR ADDRESS /^� PHONE I <br />� t <br /> TYPE OF WELLIPUMP: ❑ NEW WELL G REPLACEMENT WELL ❑ MowoRING WELL e ❑ DIE ` <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR © ;#%TRACTION WIilkf f <br /> 0 <br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. F. BT ATER LEVEL O <br /> (TYPE OF PUMPI ' <br /> OUt-OF•SERVICE WELL ❑ GEOPHYSICAL WELL I SOIL BORING 8 <br /> 1 ❑DESTRUCTION: d•: •}�`� F _ <br /> lNTEJNDED USE ,! �. TYP OF - CONSTRUCTION SPECIFICA IONS •'' "I <br /> ❑ INDUSTRIAL" ❑OPEN BOTTOM - DIA.OF WELL EXCAVATION DIA.OF Cgpro� TOR CASING O <br /> CI DOMESTIC/PRIVATE ❑GRAVEL PACK.ISIIE - TYPE OF CAI NOISTEEt1PVC DIA.OF„ L. H/G O <br /> I] PUBLTCIMUNK;rPAL ❑DRIVEN DEPTH OF GROUT SEAL �SPECIiICAT1ON A <br /> \tri <br /> ❑ IRRIGAtION1AG ©OTHER GROUT REAL INSTALLED BY UT BR*V N E f <br /> I ❑ MONITORING GROUT SEAL PUMPED: ❑Yee ❑Ne CONC E,rEDEBT BY DRILLER:❑Y. ❑No S . <br /> APPROX.DEPTH rt LOCKINO CHIESTER,0J7USTOVE PIPE 5 <br /> PIOPOSEaD CoN4TRUCT10N1DRELUNO METHOD: MUD ROTARY AIR ROTARY f:zJ41kHER= 'i? CABLE OTH <br /> --^ —^ <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THOS APPLICATION AND THAT THE WDAK WILL BE DOME IN ACCORDANCE WITH BAN JOAOUIN COU ORDINANCES STATE TAWS.AND RULES ANP <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'R 4KINATIOMW ERTIFIES THE FOLLOWING:'I CERTIFY THAT IN TI4E PERFORMANCE OF((((((THE WORK FOR WHICH <br /> ! TME PERMIT IB ISSUED.I SHALL NOT EMPLOY PERSONS SUB.IECT,TO WORKMAN'S COMPENSATION, WS OF CALIFORNIA.' CONTRACTOR'S HIRIIIG OR SUB-CONTRACT StONATURE CERTIFIER <br /> E THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERM IS,,auto.I SHALL EMPLOY iER,ONS SU&RCT TO WORKMAW4 C SATIGN LAWSOF <br /> I!i CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS 99 ADVANCE FOR ALL REOUIRED WSPQOMT s AT 12"144 -"23. COMPLETE DRAWING OW LOWER AREA PROVIDED.^� Z <br /> Signed X �..1 -!�-� ���''J' <br /> FIOT PIAN Rhaw to So:Isl Boole ''fs <br /> I 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE IIEWAGE DISPOSAL-SY,TEM OR,EItOPOBED <br /> 2. OUTLINE OF THE PRDP:RTY.GIVING MANSIONS AND NORTH DIRECTION. ExPAHMOH OF SEWAflE dSPOBAL'4Y,TEIill6: ' <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXWrNG AND PROPOSED `B. LOCATION OF WELLS WTTHN SAMS OF ONE HUNDRED.FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS OWN AS PATIOS,DRIVEWAYS,AND WALKS. - ON THE PROPERTY OR ADJOINNO FAOPERTY. <br /> � ENT <br /> It <br /> w a <br /> :.MAYS <br /> U ,. <br /> SAN JOAOUIN CU)UNTY <br /> PIj6U0 H;Ci LTH SERVICES <br /> 1�}�0.. <br /> MAY �: 1.1 vQ <br /> I-NVIAOt4MEWAI;HEALTH DIVISION <br /> ENVIF��C�EiV�A� ML1-Ff <br /> _ �1 <br /> .. P�.�FZ��iIT/SER�IC�ES <br /> cj . \\ <br /> .. . <br /> ? <br /> MAY 21998 <br /> 4 <br /> ;AN;,caxkG�iN�tSUru l v <br /> NVIR ! H DIVISION <br /> _ � oNM�rral H��r <br /> DEPARTMdiT UeE ONLY <br /> ApPileetlon Ave vied BY -� two t A,"��� <br /> { Oreu1 b"Peeden BY Oele Plenp h»peetlen Gy Doti. <br /> yI` O"ove"n Inepeetlen BY bete <br /> ` CemmerMe: <br /> I ACCOUNTING ONLY; AID' FACE <br /> PE CODES FEE INFO AMOUNT REMITTED CK/ ASH RECEIVED BY DATE PEF"TISERVICE REOtIE4T NUmsen INVOICE <br /> Pub Health Serv.-ETlviro.173(1197) <br />