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(' (PLICATION P09VELL/PUMP PER <br /> SA _ QUIN COUNTY kIBLIC HEALTH SEES <br /> r f� ENVIRONMCNTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> ���/� C2- <br /> (209)468-420 mr <br /> )uIW`� WON-REfUgOARLE PERr11TEXPIRES 1TEAR FROM DATE ISSUED <br /> 0 R I E5 I N A <br /> (Csmplsts In Triplkatel <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-9-1116.,AND THE STANDARDS OF SAN JOAQUIN COUNTY PV C HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNR47< .���/\ (� � CITY PARCEL SIZE/APN/ <br /> OWNER'SNAME - f d�"1 ADDIIE88 �"'I NEI r�� <br /> 1 C <br /> CONTRACTOR • ADDRESS LIC/ PHONE <br /> SUB CONTRACTOR ADDRESS LK:/ <br /> TYPE OF WELUPt1MP: ❑ NEW WELL ❑ PLACEMENT WELL ❑ MONITORING WELLr ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL I J <br /> ❑Now❑Rep& H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ 604 BORING S <br /> DJ <br /> ESTRVCTKIN: <br /> 44 <br /> INTENDED USE TYPE OF WELL CON RUCTION SPECIFICATIONS v A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTIGRpVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGS WJPVC OFA.OF WELL CASINO D <br /> ❑ PUBUC/MVWtPAL ❑ct"MN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED:❑Y. [IN. CONCRETE PEDESTAL BY DRILLM❑Yw ON. S <br /> APPROX.DEPTH LOCKING CHESTER SOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONIDNILUNO MIT1400: MUD ROTARY Am ROTARY AUGER CABLE OTHER <br /> I HE9EBY 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 SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-3 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR Sue-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.'�/rte(/•PPUCANT MVELL <br /> 22444 HOUR$IN ADVANCE POR ALL REGt==INSPECTION$A (2001400442!, COMPLETE DRAWING AT LOWER AREA P`RROO^VY". <br /> 84pwd X �/ 1 / �' TNI• ` ` Det• �-+ b/ <br /> PLOT PLAN Wvr to 800101 Baal• 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.GIVING DIMENSION$AND NORTH DIRECTION. EXPANCION OF SEWAGE OICPO$AL SYOTEMO. . <br /> O. DIMENSIONED OUTLNF.O AND LOCATION OF ALL EXISTING AND PROPOSED $. LOCATION OF WELD WITHIN RHINO OF ONE HUNDRED FIFTY FT. <br /> STRUC I B.INCLUDING COVERED AREAS SUCH AS PATK10,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .. .. lib :.......:.. .. ........ <br /> ........:...... <br /> :......:............................. <br /> :......:.......................:......:.... t <br /> DEPARTMENT USE ONLY <br /> Appllcatlen Aeeepted By <br /> tAN• C[ ,yr <br /> Grout Impaction BY Porro Mwpo"len ByIN ooh <br /> Daatntetlen Impeetbn <br /> Date <br /> Comments: IA p AllpA <br /> ACCOUNTING ONLY: AID$ FAC# <br /> PE CODE$ FEE INFO AMOUNT REMITTED CHECK//CA$N RECEIVED OY DATE PBeMiTf$ERVICE REQUEST 110ug9R INVOICE <br /> wvzO O O <br /> Pub.Health Serv.-Enviro.173(1/97) <br />