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APPLICATION FOR WELLIPUMP PERMIT <br /> - vAN JOAQUIN COUNTY PUBLIC HEALTH SERVi_.,- <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 408.3420 <br /> MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In TOPACNIR) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PIBLIC EARTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> ,,,///��� /t. 1 <br /> JOB ADDRESSMR APNNI\I G_ X411 /� ✓1 CITY!//, s`1 .L/ �PARCEEL gIZE/APNI <br /> OWNER'8 NAME Inc, <br /> L�La I I C QN^,� I ADDRE6 G 7/1 LG/ 'ZS// L f �I Lc�V10NE fek/ <br /> CONTRACTOR // c se I IIS NII I(1 C _Lkid./ ADDRESS I 1 /Y/UQfJ Lltij��R'Z7— PHONE IS�>2 <br /> SUBCONTRACTOR ADDRESS LICe PHONE <br /> TYPE OF WELL/PUMP:Ej24IVW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑New❑Rm.1, H.P. DEPTH PLIMP SET—FT. FIRST WATER LEVEL O <br /> ITYPE OF PUMP) <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING <br /> ❑DESTRUCTION: 'T <br /> Do/w <br /> LE <br /> INTENDED USE TYPE OF WECONSTRUCTION SPECIFICATION& � <br /> ❑ INDUSTRIAL W ���❑'LL OPEN J <br /> �N BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTIC/PVATE CE3:QNAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASINO D <br /> ri <br /> ❑ PUBUCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> RIGATION/AO ❑OTHER GROUT SEAL INSTALLED <br /> �D B(V' GROUT BRAND NAME LL ( rs E> <br /> El MONITORING f� / GROUT SEAL PUMPED: &M ❑ PLL <br /> Ne CONCRETE PEDESTAL BY ER:❑Y. Oy` S•-1. <br /> APPIOX.DE". . � LOCKING CHESTER BOXISTOVE PP S.4- <br /> PROPOSED <br /> .*PROPOSED CONSTRUCTION/ UJN0 METHOD: MUD ROTARY ✓C AIR ROTARY AUGER CABLE OTHER <O <br /> J <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL EMPLOY PERSONS BUBJECT TO WORKMAN'S COMB *AT10N LAWS of <br /> CAUFORNIA..'' THIS ARUCIUT M�US//TEDC.A`LL/p4 HOURS IN ADVANCE FOR ALL REQUIRED INSKCTIONO AT(]OS)401 422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> SIpn.4 X J/ (T L /I/FY✓C.L i�KI TIIIe �,A I(ll1'vl D.I. <br /> MOT WAN IO—to Bo.I.I S 1. m <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION Of SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> /nV <br /> goy <br /> `I <br /> b l�;,)gil <br /> PAYMENT � <br /> gooSEP m aax € <br /> L �n�( 5 1997 <br /> SAN JUAUUIN COUNO' <br /> PUBLIC HEALTH SERVICES 1 <br /> FNVIHQNMENTcI HFAI TH DIVISION <br /> 1 DEPARTMENT USE ONLY <br /> Avvlla.tlpn Acpeptetl BY DILA S— Ar.. 2­11 <br /> Gmm Iropallpn BY Oa. I G Pump In.P.0.n BY D.t. <br /> Dslruetlon Impatlon BY D.R. <br /> /�� I <br /> l <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE COD" FFE INFO AMOUNT REMITTED HECK CASH RECOVEO BY DATE PFHMITISERVICE REQUEST NMIIRM INVOICE <br /> G' ayP L% 35� 3 0135 <br />