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�I <br /> APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOA <br /> ourN c <br /> OUNTY PUBLIC HEALTH <br /> SERVICES <br /> ENVIRONMENTAL 304 EAST W BER AV NUE,,STOCKTON, CA 95202 �LTH DIVISION ply <br /> (209) 468-3420 ' <br /> NOK-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompl&ts i8 Triplicate) <br /> APPLICATION 49 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1 1 15,3 AND THE srAqnAnos OF SAN JOA IN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDREBWOR APNI ,L} � /��''� dF <br /> ��I�W -� PARCEL81ZE/APF]I <br /> OWNER'S NAME ADmas PHONE I <br /> _qff—z 7404 <br /> CONTRACTORZOK4W - r l,, <br /> ADDITE$$ QD k7 • 1C1� E PHONE t <br /> SUBCONTRACTOR ADDRESS I LiceCI PHONE <br /> TYPE OF WEI.L/pUMP; 'CTM NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ CJ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> {TYPE OF PUMPI ,I <br /> ❑Naw©Rep.ir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL - O <br /> © OUT-0F-SERVICE WEtt ❑ GEOPHYSICAL WELL I ❑ SOIL BORING g <br /> li <br /> ❑DESTRUCTION; <br /> INTENDED ViE TYPE OfELL CONSTRUCTION SPECIFICATION& A <br /> © INDUBTmAL ❑OPEN BOTTOM <br /> DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO <br /> {(`}_ D <br /> -D01yIE@TICIMS VATE �,/ <br /> RAVEL P 7C <br /> S� ACXl81ZETYPE OF CASINOlSTEELA^VC !�/C/ DIA.OF WELL CASINO_6 //>,/ D <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL /06PT ,—_ SPECIFICATION a <br /> ❑ IRRIOATIONIAO 11OTHER GROUT SEAL INSTALLED BRILL <br /> BY GROUT._/Ldp1T]F�i GROUT BRAND NAME <br /> 11MONITORINGBEAt4 <br /> MONITORING - <br /> L PUMPED: N ❑Na CONCRETE PEDESTAL BY DRILLER;cry.(pN.- S <br /> AP X.DEPTH_ LOCKING CHESTER BOXISFOVE PIPE <br /> 5 <br /> PROPOSED CONSTRUCTION/DIOLLINQ METHOD- MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE%BY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOFK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUOI COUNTY, HOME OWNER OR LICENSED AGENT'@ SIGNATURE CERTIFIES THE FOLLOWING;'1 CERTIFY THAT IN THE PEWORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 9HALt NOT EMPLOY PERSONS SUBJECT TO WORKMAN-6 COMPENSATION LAWNS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SU"ONTRACTMG SIGNATURE CERTIFIES <br /> THE FOLLOWING; 'I CERTIFY HAT M E PERFORMANCE OF THE WOFK FOR WHICH THIR PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF <br /> CALIFORNIA.' A MUST UR&IN ADVANCE FOR ALL R4OURED INS N!AT 1 14eSa42s. COMPLETE DRAWINO AT LOWER AREA PRO OED. <br /> 8kned X <br /> Tift Dt[r O <br /> PLOT PLAN IDtrw to Sa.1.l%.lr •is <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,OIVINO DIMENSIONS AND NORTH DIRECTON, EXPANSION OF$EWAOE DISPOSAL SYSTEMS. <br /> 7. DIMENSIONED OUTLINES AN13 LOCATION OF ALL EX19TRM AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH All PATIOS,DRIVEWAYS,AND WALKS. ,ON THE PROPERTY OR ADJOINMO PROPERTY, <br /> s <br /> 54 ve <br /> .Sym. <br /> PAY . <br /> E- pIR .. <br /> ,.. �IAY 2 6.1998 : <br /> SAN JCAQiAN Cl71JN1 Y <br /> 1 <br /> 5 <br /> PUBLIC HEALTH SERVICES <br /> ' ENVJRONMC-IVTAL HEALTH DIVISION <br /> DEPARTMENT USE ONLY / pv <br /> A,pllr.11on Aoaaptad BY bnr 1. 21 <br /> GraUt Irnpeatbn By Drtr �7 Pu-p Inepa.tlon By Date <br /> OeagrclCenJ I eetlen`BY ��� �y, Iy'� lir-, � DNa r <br /> Cemmer7lJ: <br /> ACCOUNTING ONLY: AIO/ FAG <br /> PE CODES FEE INFO AMOUNT REMITTED K./ ABN RECEIVED■Y DATE P9INBTISERVICE REQUEST NUMBER INVOICE <br /> 3 t.•� 7 5-0 <br /> 61q1�8 <br /> Pub Health Sere.-EnviTO.173(1/97) <br />