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SAN APPLICA110N FOR WELLIPUMP PERMIT \ <br /> JOApUIN COUNTY PUBLIC HEALTH SERVICES I % V <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 398, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201388 <br /> (209) 4883420 <br /> APPLICATION IS HERE BY MAGE TO THE SAN JOAOUIN COUNTYN DR AUNOABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOApCA COUNTY DEVELOPMENT ICnmpMb in irpliegb) <br /> EVELOPMENi�T LE,CHAPTER 8 I 5.3 AND THE STANDARDS OF SAN JOApUIN COUNTY PLIBIIC HEALTH SERVICES, IS APP ENVIRONMENTAL HEALTH IN COMPLIANCE <br /> 1 PERMIT R CONSTRUCT ANDIN COUNTY THE WOW DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIAryCE WITH SAN <br /> J08 ADOgESSIOR/A'P/NtI• ��J O S // „ / c <br /> OWNER'S NAME I�I:.//���V( /t / A N/ ^ CITY_J t <br /> CONTRACTOR CC(�F/1�(W_ N L C /f ADDRESS PARCEL SIZE/APNI J <br /> C ZL,� 5l4A/ <br /> SUR CONTRACTOR ADORE 66 202Y E 1 ( JYIr PHONE e �J</ <br /> TYPE OF WEU Y,UMP ADDRESS —PHONE I <br /> -- NEW WELL LICA <br /> ❑ REPLACEMENT WELL — _PHONE <br /> ,❑,.,�INSTALLATION ❑ WELL SYSTEM REPAIR MONITORING WELL A <br /> ❑ CROSS CONNECT REPAIR El OTHER_ <br /> RVPE OF PIIMPI �aw❑Reeelr N.C� ❑ VAPOR EXTRACTION DEPTH PUMP SET�FT. <br /> El ❑ OUT OF-SERVICE WELL FIRST WATER LEVEL a <br /> DESTRUCTION. � GEOPlIVSICAI.WELL♦ O <br /> SOIL BORING-- V� <br /> INTENDED U S UI <br /> I] IN1)USTRIgI TYPE OF WELL <br /> 11�--..�OPEN BOTTOM CONST <br /> OF WELL F CAVATICAT10Ng C' <br /> DOMESTIC/P111VATE LGGg VEL PACK1812E 2—/ DIA.OF WELL EXCAVATION 2 q <br /> 0PUBLICOAVNICIPAL <br /> TYPE OF DIA.OF CONDUCTOR (Qv� A N <br /> ❑ IRRIGATION/AG �ORIVEN ( D <br /> ❑OTHER DEPTH OF GROUT SEAL Zoe DIA'OF WELL CASINO�p � // 'T <br /> ❑ MONITORING GROUT SEAL INSTALLED BV C L r. SPECIFICATION <br /> ��J7 / ! <br /> APpgO%.DEPTH� i,U� ,,C GROUT SEAL NMPED: �Ne GROUT BRAND NAME WFS v E� <br /> �V�V_ a <br /> PILOMSED CONSTRUCTIONRMSWNO METHO AM LOCKING CHESTER BOX/STOVE PIPE CONCRETE PEDESTAL By OgILLFq: <br /> r ON. g <br /> AIR ROTARY AUGER S S <br /> I HEREBY CERi1FY THAT I HAVE PREPARED THI6 CABLE OTHER REGULATIONS OF THE SAN JOAOUIN COUNTY. HOM II OWNER OR LICENSED A ENT'S SIGNATURE CFRTIpE6 THE Fo <br /> THIS �WILL SE DONE IN ACCORDANCE WITH BAN JOADUIN COU <br /> PERMIT IB ISSUED,I SHALL NOT EM <br /> THE FOLLOWING: I l'ERt1FV THq PLOY PERSONS BVBJECT TO WOq NTV OgOINANCE6,STATE LAWS <br /> KMAN'8 COMPENSATION LLONnNG;•I CERTIFY THAT IN THE PERFORMANCE OF AND RULES AND <br /> CALIFORNIA.• T Ap M RFORMANCF OF THE WOIK FOq_ LAWS OF CALIFORNIA.• CONTRACTOR'S HIRING OR 6U8-COM THE WpgL FON WHICH <br /> C NT T A A/.7/ Ugg IN ADVANCE FOq ALL gEOUgEp INSpRMR IB I68UED,I SHALL EMPLOY <br /> PERSONS SUBJECT TO WORKMAN'S COUMN ATION LAWS CERTIFIES <br /> 61pne!% /^ ,/� ONS AT @OSI NBJA30. COMPLETE DRAWING AT LOWER AREA Pq0 <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING ME fNOPEgTyel 6cele D.m <br /> 2. ONLINE OF THE PROPERry,GIVING DIMENSIONS AND NORTH DIRECTION. 1e <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PRO TIO A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR <br /> STRUCTURES,INCLUDING COVERED AREA SUCH AS PATIOS,DRIVEWAYS,AND WALKS. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> PROPOSED <br /> S. LOCATION OF WELLS WITHIN <br /> RADIUS OF ONE HUNDRED FIFTY <br /> ON THE PROPERTY OR ADJOINFT <br /> QcLt�IIU <br /> t'id'YPLL1kP�1! Q <br /> SEP 5 1995 <br /> JAN JOA W L j,q <br /> "JBIIC <br /> LNVIf70NMENTALiIHSEhI/it:.F� I <br /> A' <br /> II q a etl By DEPARTMENT USE ONLY <br /> ut In.Pmtlen BY .1. l cl 3 7 0 <br /> Pump ImPatlon BY Ara <br /> vudl°n In.patlon By <br /> (] , <br /> n D.te 4 pI /� 1� <br /> Imenb: r I/ Dem <br /> CCOUNTIND ONLY: <br /> AIDl <br /> FACS <br /> E CODER FE INFO AM LINT REMITTED <br /> CNEC ASN RECEIVED SY <br /> 2^ Z� DATE pLTMIT/BpiViCE REQUEST NUMBER <br /> INVOICE <br />