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APPLICATION FOR WELLIPUMP PERMIT <br /> ..eAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PA BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 466.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Com <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT I CTANO/on 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 /> JOB ADDRESSOR APNI P�(j UPJ. Nd.!(hY. S�.Q 'C'I�!��' f[� <br /> CIT-11 PARCEL PARCEL BIZE/APNR <br /> OWNEn'8 NAME ( fn r h(� h— ADDRESS / �C (�.� <br /> y - 'Rj^��e'rry]�-+-1/J PFIONE M q�Q��-�p�pSf�L,! <br /> CONT MCTOR = [_ fl� ADDRESS 1 71`] tM/i7 �yj �S�/O/[f(,`/ P410HE# <br /> RVB CONTRACTOR IIS TIG' <br /> PHONE# b X037 �f5(cj <br /> TYPE OF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> J <br /> New C1Repelf H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) O <br /> ❑ DVT-OF SERVICE WEL1. ❑ GEOPHYSICAL WELL 1 SOIL BORING D e <br /> ❑ <br /> DESTRUCTION:— <br /> LS E <br /> ESTRUCTION:SE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM A <br /> DIA.OF WELL EXCAVATION_ III DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC— N!Y <br /> DIA.OF WELL CASINO D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ r7-+ 'p <br /> / 1T �` SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT GROUT BRAND NAME <br /> C1MONITORING EGROUT SEAL PUMPED: I2(Ys ❑Ne CONCRETE PEDESTAL BV DRILLER:❑ []No No S <br /> APPROX.X.DEPTH _ LOCKING CHESTER BOX;r.r 'i,,t{IPE <br /> PROPOSED CONOTRUCT10NnM0LUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE._ _ OTHEnj)/Y'�� �(,(�/ <br /> I HE9EBV CERTIFY THAT 1 NAVE PREPARED THIS APPUCATION 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 AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFOnMANCE OF THE WORK FOR WHICH <br /> T1118 PERMIT IS 188U ,1 TALI NOT EMPLOY PIE N8 SUBJECT TO W RKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 1 CE IFY THAT IN TIIE MANCE THE RK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T APPUC NT MU$T CALL 1 F URS FOR ALL REGUIRED INSPECTIONS AT 12001440-3423. COMPLETE DRAWING AT LOWER AREA PRO ED. <br /> Slpned X c TltleQ IZ3 <br /> PLOT PLAN(Drew to Boole)Soele to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TIIE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,01VIN43 DIMENSIONS AND NORTH DInECT10N. EXPANSION OF SEWAGE DISPOSAL SY97 EMS. <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 AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> chDEPARTMENT USE ONLY <br /> APplloetlon Aoeepted BY- bebAr so U,P <br /> .. � //. <br /> Gf t I—Peeflon BY Dete_ R1mp ln�peetlen Dole <br /> beet—fl—I—peetlon BY__ <br /> ACCOUNTINO ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CNE <br /> 10"811 RECEIVED BY DATE PEOWIT161MVICE REQUEST NUMBER INVOICE <br /> ��o pO 089 b <br /> 6� 8Z <br /> Pub.Health Serv.-Enviro.173(3/96) <br />