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y x� <br /> 7 APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY'PUBLIC HEALTH SERVICES <br /> 6 [>�� ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9520! 88 <br /> (2091460-3420 <br /> NOW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Ttipli6/t6) <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JORADDRESS/ORAPN/ 1 3650 E7d /A <br /> E.7,,Sargent R_ . _ - citY Lodi Ca PARCEL8IZE wO53-040-22 <br /> OWNEWIINAME Brian Colburn ADDRESS P.O. Box 754 Clements PHONES <br /> CONTRACTORPUrvlanCe Drillers Inc ADDRESSP O Box -6-"Lnd nuo,377923 PHONE,$87 355A <br /> SUS CONTRACTOR n/a ADDRESS <br /> LIC/ PHONE, <br /> TYPE OF WELIIPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL, ® OTHEnbaclC flow prevention <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL, <br /> J <br /> New❑Repdr H.P. DEPTH PUMP SET FT- <br /> {TYPE OF PUMP1 FIRST WATER LEVEL d <br /> ❑DESTRUCTION: ❑.OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL, ❑ 8016 BORING <br /> 8 <br /> INTENDED USE TYPE OP WELL CONSTRUCTION$PECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM . A <br /> DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO D <br /> ❑ DOMESTICONUVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEUPVC <br /> - DIA.OF WELL CASING D ' <br /> ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION .. '�• <br /> ❑ IRRIGATION/AG ❑OTHER R <br /> GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ RMONITORING DEPT GROUT SEAL PUMPED: Ely. ❑Ns <br /> CONCRETE PEDESTAL BY GRILLER:❑Yw ❑Ne S <br /> APPROX.DEPTH LOCKING CHESTER 80XIBTOVE PIPE <br /> PHOPOBED CON11TRUCTIONIDRILLING METHOD: MUD ROTARYS <br /> AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WGRK FOR WHICH <br /> THIS PERMIT is ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CAUFOFINIA,' CONTRACTOR-8 HIRING OR$UB-CONTRACTING SIGNATURE CERTIFIE8 <br /> THE FOLLOWING; 'I CERTIFY IN THE PERFORMANCE.OF THE WOW FOR WHICH T1418 PERMIT.18-18SUED,1 SHALL EMPLOY-PERSONB BUBJECT�TO�WORKMAN'/CpMPEN6AT1gN LAWS OF <br /> CALIF A. E APPIJCAH VST LL 24 HOURS IN ADVANCE FOR ALL RF.QUt11Eb INSPECTFON6 AT 12061400-2422, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 810"w X 4 Title Corporate Secretary ,,,, T_ 3/1 7/97 <br /> bate <br /> PLOT PLAN(brow to Sadel Bade ^to <br /> t. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, <br /> 2. OUTLINE OF THE PROPERTY,OWING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIO B,DRIVEWAYS,AND WALKS. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNbRED FIFTY FT• <br /> ON THE PROPERTY OR ADJOINING PROPERTY, <br /> r : ......, ...... ...:..... .'. .... <br /> - <br /> �.. NCu�pump. <br /> HLIIINEA <br /> `r <br /> 1 i!Ell <br /> DEPARTMENT USE ONLY <br /> Appllaeltvn AceepleA By � 1 11 <br /> bete Ara <br /> Oraut lmpxtlon SY Oats_ _ I„ Pump Impaction S a <br /> Dntrmlion lrnpeatlen Sy <br /> Date <br /> Date <br /> Cammenh; . I <br /> C <br /> ACCOUNTING ON AID, FAC, <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK, ASH RECEIVED SY <br /> DATE PI3NAIT! ER VICE RE VEST NVM861 INVOICE <br /> v moo 1i�L� <br />