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APR 12 2000 <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> EAST WEBER AVENUE, STOCKTON, CA 95242 400Z 8dV <br /> (209) 468-3420 <br /> NOW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> [calegles M TylgincEtal <br /> APPLICATION IS HERE BY MADE TO THE SAN 30AOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW Of SCRIBED.T1118 APPLICATION 19 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> r JOB ADDRESS/OR APNI r Vy 1 r�L r � CITY PARCEL SIZFIAPNI if <br /> OWNER'S NAME �v�'�' �'�t''n. <br /> ADOUI u(J ' 'J� {� { PHONE f L r�3 <br /> CONTRACTOR t� 1- �' A-,,S oc'c,4--s ADORE.. ``�Q�p w�" �G`rte. - V LIC/ r PHONE 0-5 r�y!/ <br /> SUS CONTRACTOR -�Gh L•��''• ADORESS �1 r 5� 'rl� [ uC. IDi 33 PHONE+I 7'f Z <br /> l <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL• ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> l ❑New❑Rma[r H,P, .,DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> ITYPE OF PUMN <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL 0 � SOIL BORING � � � 8 <br />{t{ ❑DESTRUCTION! <br /> S INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS l l A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION - DIA.OF CONDUCTOR CASINO I ILA D - <br /> GRAVEL PACK/B9715 88L�C I� <br /> + V� � GIA.OF WELL CASINO � I <br /> ❑ pVBLICIMUNICIPAL ❑bn� DEPTH OF GROUT 6EA <br /> _ O <br /> .L +S♦ SPECIfICATION R <br /> }❑�IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY I�l'NLi GROUT BRAND NAME vi �lTt. CQ.Lv��" E <br /> J MONNOIUNG GROUT 6EAL PUMPED: ❑Yr. a CONCRETE PEDESTAL BY DRILLER:❑Yrr allo S <br /> APPROX.DIFTH LOCKING CHESTER BOXMTOVE PIPE , S <br /> 1 PROPOSED CONSTEIUCTTONIMLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1111 I HE4fBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK 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 WORK FOR WHICH <br /> TMS PERMrT IS ISSUED,I SI4ALL NOT EMPLOY PEA90NB SUBJECT TO WORKMAN'S COMPMIIATWN LAWS OF CAtJFORMA.- CONTRACTOR'S HIRING OR BUBZONTRACTINO MNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THIS PERFORMANCE OF THE WOW FOR WHICH THIS PEAMTT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPOINSATION LAWS OF <br /> CAUFORMA..' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSMTIONS AT 12"j SS*-U". COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> I SbnedX L Y\M_L.� Jt>hf Yi�.�—C�� Title �[,t � n Q." /�,/ vat! <br /> PLOT PLAN 10—to Banal Bede '10 <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY, ♦. LOCATION OF HOUSE SEWAGE Dtepom SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DMAEN81ON8 AND NORTH DIRECTKTN. EXPANSION OF SEWAGE DISPOSAL SYSTEMS.. <br /> 3. DIMENSIONED OWTUNFB AND LOCATION OF ALL EXISTING ANO PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALXS,. ON THE PROPERTY OR ADJOINSKT PROPERTY, <br /> Z <br /> -. • i W � Q - ... <br /> :71� A <br /> DEPARTMENT USE ONLY- <br /> Applir►tlon Aaraetad Bye 0•t• - Mee . <br /> 0,*tA"poetlen BP Date Rump IMPe tion By Datr <br /> 0-1—tlon 11—pwt By bate <br /> f <br /> ACCOUNTING ONLY: AIG/ FACS �r(J/a - <br /> PE CODES TEE INFO AMOUNT REMITTED CHECKIMASH RECO ■Y DATE P90MITISERVICE REQUEST NUYISEII a INVOICE <br /> S ZZ 33.5 <br /> t <br /> Pub LSeaith Serv.-Enviro.173(1/97) <br />