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SAN APPLICATION FOR WELL/PUMP PERMI' <br /> OUIN COUNTY PUBLIC HEALTH SERvlCEQ 0D <br /> cNVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95 a <br /> 202 / <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C(//I _ <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY Fpq A 7 25.3 3 a <br /> JOAQUIN COUNTY (complete In 7ripliettt► <br /> Z Z_N,•� vE PER R CONSTRUCT AND/OR INSTALL THE WOFiC DESCRIBED.THIS APPLICATION <br /> E LOPMENr Tfitf CHAPTER 8-11 1^1 5.3 AND iNE STANDARD,OF gq�.�JOAOUIN COU <br /> JOB ADDRESS/OR APNI �G-/n/ { NTY PUBLIC HEALTH SERVICE,,ENVIRONrNENTAL HEALTH OI COMPLIANCE WT71f SAN <br /> CCC. 6 CEE v�s�pN <br /> OWNER'S NAME &491NJL Cm �k I /"cam <br /> _�� PARCEL SIZ <br /> CONTRACiO♦ f- � T Y ADDRESS L (-' E/ApT.I! / <br /> � ,1 n <br /> ADDRE68 l,%, A PHONE <br /> �BVB coh rF vgCTOR fil.�cls,�^, //r��� {�/3 /� , /, \ <br /> • V -� � C3�J� PHONETYPE OF—L/PUMP: ❑ NEW WELL CtPHONE❑ REPLACEMENT WELL <br /> �Al)onts�. <br /> fTORINO WELL I <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ��• OTIfFq !gyp //� <br /> �_ <br /> El N_❑ ❑ CROSS-CONNECT REPAIR � G��'�•�nU <br /> RyPI OF PUMP, Revolr M.P. ❑ VAPOR EXTRACTION WELL! ,Cot <br /> DEPTH PUMP SET /i <br /> FIRST❑ WATER LEVEL WELL OEOPIyBICAL WELL I <br /> �-' ONOESTRUCTION: &� �V T <br /> SOIL BORING <br /> If A- 8 <br /> INTENDED USE , em o" <br /> �-- TYPE_ p=yyELL n n <br /> ❑ INDUSTRIAL El OPEN BOTTOM CONtigUCTION SPECIFICATION! cepreA <br /> ❑ DOMESTIC/PRIVATEDIA.OF WELL EXCAVATION �• j l� <br /> 7 <br /> PUBLIC/MUNICIPAL ❑GRAVEL PACK/SIZE EJ DRIVEN <br /> OF CONDUCTOR CASINO /9 <br /> DRIVEN TYPE OF CASINO/STEEL/PVC �U( <br /> IRRIGATION/AO <br /> DEPTH OF GROW SEAL Q — DIA.OF WELL CASINO O <br /> OTHER ,"�syy1)j�� S >•hr L- <br /> F SPECIFICATION � <br /> _ MONITORING GROUT SEAL INSTALLED BY ►� <br /> i L fpr I• GROUT BRAND NAME _/' R <br /> kppno X.DEPTH 11II GROUT SEAL PUMPED: ❑Yep�No v) �C�' f•CQ{ <br /> CONCRETE PEDESTAL BY DRI f <br /> ROPOSED CONS TAUCT1ONMMLUNO METHOD: MUD LOCKING CHESTER BOX/STOVE PIPE /� LLER;❑Yw <br /> iWTARY S <br /> ��AIR ROTARYe_ <br /> IE7E8Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE Wp AUGER—CABLE S <br /> -- <br /> �OTHER c_eU <br /> GULATIONS OF ifiE SAN JOApU1N COUNTY, HOME OWNER OR LICENSED AGENT 6 GNAT URE CERTIFIES THE OLLOWINO^N CERTIFY THAT IN THE PfrVORM <br /> 116 PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOgKMAN't COM JOAOVIN COV <br /> It FOLLOWING; PITY HE PFR NCE,,STATE LAWS,AND RULER AND <br /> 1 CERTIFY THAT IN THE PERFORMANCE OF THE PEHSATION LAWS OF CALIFORNIA CONTRACTOR'S HIMNO OR SUB-COMTRAC71N0 BIG NATURE CERTIFIER <br /> �LIfORN1A.• APPLICANT VtT CALL Z1 HO ��FOR WHICH THIS ANCE OF THE WpgK ppq WHICH <br /> IN ADVANCE FOA ALL REOUIq ED INt PFRMr7 IH ISSUED,1,HALL EMPLOY PERSONS SUBJECT 70 WORIONAN't COMPENSATION LAWS OF <br /> ned X PEC T10Nt A7 12Ot1�ttJ4tS, COMPLETE ORAIVINO AT LOWER AREA Pf10 VIDEO. <br /> NAMES OF 67REETH Oq PI07 PIAN IDrow,o gods D�te�/�,/OC <br /> OUTLINE OF THF ROADS NEAREST TO OR BOUNDING THE PRO PE I Bede Yte <br /> PROPERTY•DIVING DIMENSIONS AND NORTH OIIIEC7IORNry <br /> ')IMENSIONED OUTLINES AND LOCATION Of ALL EXISTINGDNO AND TRUCTURES,INCLUDINp COVERED AREAS SUCH PATIOS pql �- LOCATION OF SEWAHOUSEGE <br /> E DISPOWAGESAL <br /> AL SYSTEMS.SYSTEM OR PROPOSED <br /> PROPOSED EXPANSION OF BEWApE DI8P08 <br /> DRIVEWAYS,AND WALKS. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDREDFIFTY FT <br /> OH THE P'ROPEr{Ty OR ADJOINING PF10pERT-y, <br /> s •... <br /> J Lf <br /> .............:.......:.... <br /> EPMTM _......_,......:..... <br /> -11—Accepted By ENT USE ONLY / <br /> 'rnpxllon By Dot• �'/ � �� O//T .Y <br /> Dote A, <br /> algin Irnnectlon ��Po^P Irnpeotlon By <br /> Dote_ <br /> COUNTING ONLY. <br /> AID,! <br /> FACT <br /> 'ODEt FEE INFO AMOUNT R ITTED <br /> CHECK!/CASH RECEIVED BY <br /> d DATE PERMIT/tER,610E REO UEST NUMBER <br /> /DD INVOICE <br /> OZ <br /> alth Serv.-Enviro.173(1/97) <br />