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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388,304 EAST WEBER AVENUE, STOCKTON. CA 9S20t388 <br /> _ 1209) 4693420 <br /> E Q n- t NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUER <br /> (Complete In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOP A PERMIT TO CONSTRUCT ANOMn INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TRTU.CHAPTER 9.1115..31AND THE STANDARDS <br /> OF SAN JOAOUIN COUNTY PUBLIC 14EA/�/]11 SYERVICES,ENVIRONMENTAL HEALTH OMS RN. <br /> JOB ADDRESSOR APNf�� <br /> /� PARCEL SIZE/APER( <br /> OWNER'S NAMES 4/L^i Y AOOMOR �T Wim.- PHONE a •E <br /> CONTRACTOR UPI. (�(�- 2[� [� P� c- ADDRESS ! UCE�P10NE E� /-A y <br /> OUR CONTMCTOR ADDRESO Me RHONE a I <br /> TYPE OF MUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORINO WELL a ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR El CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL a J <br /> ❑Nw panptlr H.P. DEPTH PUMP BET�JT. <br /> FIRST WATER LEVEL__ n <br /> D YPE OF PUMP( <br /> ❑ OWAFSERV6F WELL ❑ GEOPHYSICAL WELL a ❑ BOIL BORING n <br /> ❑DESTRUCTION: <br /> r.INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO D <br /> ❑ DOMESTICBXR ATE ❑GRAVEL PACKGRZE TYPE OF CASINO/BTEELIPVC DIA.OF WELL CASINO n <br /> _❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION R <br /> 0YARIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME F <br /> ❑ MONITORING OMUTSFALMMPED: ❑VHS ❑N. CONCRETEPEUESTALBYDRILLER:❑Ye. ❑N. S <br /> APPROX.DEPTH LOCKING CHESTER ROXMTOVE RPE e <br /> PROPOSED CONSTRUCTIONRNIILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY TI4AT I HAVE PREPARED TWO APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AHD <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF TIIE WORK FOR WHICH <br /> TIIIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB.CONLMCTING SIGNATURE CHUIFUG <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERPORMAN OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM 2ATIO I LAWS OF <br /> CALIFORNI A CANT MUST CA/LL/=/S/.y Ma ADVANCE FOR ALL.NEUUHIED IN4aE nO,N4 AT(X0q 4001422. COMPLETE ORAWING AT LOWER AREA PADVIDED <br /> —Bbrd�i' T FY S � clq <br /> ` MOT PLAN ID,.w.1.S.M.I B••I• •le <br /> I. NAMES OF STWIFTS OR MADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OO ITOMSEO —1 <br /> 2. OUTLINE OF THE PgPERTY,GIVING DIMENSIONS AM NORTH OmF.CT101. EXPANSION OF SEWAGE DIBMSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOININGire <br /> PgPERTY. .A <br /> V <br /> L <br /> 1 i s <br /> t{ 17 r ce u)c`f' <br /> PAYMENT <br /> � <br /> SEP 2 3 1997 <br /> aVLJJUA�_uiNcuulvr� . <br /> JPUBLIC HEALTH SERVICES. _ p0 <br /> IENViRONMEN'AL HEALTH DIVISK W <br /> �A DEPARTMENT USE ONLY <br /> nP.ne.lbn AeewplM BY rJ Li A E'l D•�u 4-1 A,•• <br /> G,oN In.P,elbn BY O.I. P p Inn.—V.G By •l�Y/wrc1� D�.M'T�2/C.(y-7 <br /> Dralsn.n Vvneeew.BY__ Dwa <br /> Cemman.: <br /> ACCO UN TIN.ONLY: AHF FACa <br /> PE CODES FEE INFO /(MOUNT REMITTED HEC E ABN RECEIVED BY DATE M NIT/SERVICE REQUEST NUMBER INVOICE <br /> ZIF ,20 9 04 I? 1 <br /> Pub.Health Saw.-Enviro.173(3/96) <br />