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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> e-,�l (209) 468-3420 <br /> rCA ✓H'L IJ rC-aQ OCx `'� MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> IC*mpMt*IB Trlp9e*t*I <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDOR INSTALL THE MAN DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE W1711 BAN <br /> JOAQUIN COUNTY DEVELOPMENT <br /> CT,RIS,�CHAPTER 9-1115.3.AND/THE STANOARDR OF BAN JOAQUIN COUNTY PUBM HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, <br /> JOB AODRESSMR APJI 1 7 / ) Ll CITYS�t.l 7e-' PARCEL SMF/APJ1 <br /> OWNER'S NAME ( L I ADDRESS H4..EN 61 <br /> I kI 7 q�- /J BONE f <br /> L <br /> CONTRACTOR '/Y� A / ADpR88 /^ l(. UC/ PHONEfSI��.✓t�2Y <br /> RUB CONTRACTOR ADDRESS UC/ RHONE/ <br /> TYPE OF WELL MP: ❑ HEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTNEP <br /> Gl`y^/..� ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CM88-CONNECT REPM�^jI f ❑ VAPOR EXTRACTION WELL I �//-- <br /> ❑. .YHPR...I. H.p.� DEPTH PUMP BET /Fl: , FIRSTWATERLEVEL <br /> RYPF OF PUMP) <br /> ❑ OUT-OF SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ BOIL BORING B� <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q <br /> ❑ INDUSTRIAL 11 OPEN BOTTOM CIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> IKDOMESTICIPVVATE 1:1 GRAVEL PACKIBRE TYPE OF CASINO/STEEUPVC DIA,OF WBL CASINO D <br /> ❑ MOM/MUNICIPAL ❑DRIVEN DEPTH OF GROUT REAL SPECIFICATION R <br /> ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E / <br /> ❑ MONITORING ORDVT SEAL PIMPED: ❑YM ❑Ne CONCRETE PEDSTAL BY DRILLER:❑Yr ON. S CJ <br /> APPROX.DEPTH [/O LOCKING CHESTER SOX/STOVE RPE ,S /L <br /> PROPOSED CONSTRUCTION/O18LLIN0 METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I NEWRY CERTIFY THAT I HAVE PREPARED THIS APPIICATKJN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAW8.AND RULE*AND F <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OMRIER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 MIND,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEIISATION LAWS OF CALIFORNIA.- COW RACTOR'8 HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMO IS ISSUED.I WALL EMPLOY PERSONS SUBJECT TO WGIOAAN'*COMIdB DOM LAWS <br /> OF <br /> CALIFORNIA.- T T MUST CALL ti HIO AD%/N/%flVE FOR ALL REOUNIM 1014 TbNB AT 1]OS 404 8 S. COMPETE DRAWING AT LOWER AREA PIOVIDEO. <br /> elp..d x c jAT_nnl / Qf D.R. <br /> PILOT Pun ID....N,Sp.l.l 0..1. •R. <br /> 1. NAMES OF OFFSETS OR BONDS NEAREST TO OR BOUNDING THE PPRDPIRY. S. LOCATION OF HOUSE BEWAUE DIBPOSAL SYSTEM OR PROMISED <br /> }, OUTLINE OF THE PROPERTY,G1V8q DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWARE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AM P IOMBEO S. LOCATION OF WELLS WITHIN RADIV8 OF ONE HUNDRED FIFTY FT <br /> STRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIO8,DRIVEWAYS,ANO WAULS. OH THE P'ROPRTV OR ADJOINING PROPERTY. <br /> PAYMENT <br /> AYM <br /> RFC* -IVI.Fn . <br /> i' DEC 3199$ . <br /> SAN JOAOUIN COUryTY <br /> PUBLJC OAQUI SEflVICES <br /> I <br /> TD PMTMOTT USE ONLY I J 2 <br /> Avplla.11en Am*pNW BY L \ '� D.I. • Y' 3 1? MY <br /> G.eu Irwp«Ren Br D.H. Pump lo.P«nem ar / O.R. <br /> Dml..clle�L.n«II«Rr Ow. <br /> CemmwX.: <br /> ACCOUNTING ONLY: AIDS FACE <br /> PE Coot* FEE INFO AMOUNT ROAITTED CHECK/ ASN RECEIVED SY DARE PORMIT/SERVICE REQUEST NUMBER INVOICE <br /> OAU $�-GLS S 7 <br /> ,D Health SON.-Enviro. 173(1/97) <br />