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APPLICATION FOR WELLIPUMP PERM <br /> SAF!JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 389,301 EAST WEBER AVENUE.STOCKTON.CA 95201-388 <br /> (209)461.3420 <br /> r.0r-9EFUMPINLE PERM EXPMES I TEAS FW!ITATf ISSUEII <br /> ICtnphtt M TNt(IrNettt) <br /> APPLICATION IS HEPE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WOFK DESCRIBED.THIS APPLICATIOr4 is MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER 9-1115.3 AND THE STANDAFn9 OF SAN JOAQUIN COUNTY PUBLIC H'ALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNF Z Q O I Al/' A//j St CITE-7_MF►n /• PARCEL WZF/AFYI/ <br /> OWNER'S NAME_ O S&E/j F�Q_rG ADDRESS— 0 / i/n J�. PHONE I p-' <br /> 74-1 <br /> / <br /> CONTRAC70R V,�e:A,-� Dr ApOR£R6p• 'r PI/ONE <br /> SUB CONTRACTOR �•-� `✓ ADDRESS UCI PHONE F <br /> TYPE OF WELLMUMP: C1 NEW WELL ❑nEPLACEMENT WELL ❑MONITORING WELL• ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CON14ECT REPAIR ❑VAPOR EXTRACTION WELL F <br /> R VPf OF PUMPI <br /> 11N—❑Rep•;, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> �[ <br /> ❑OUT-OF-SERVICE WELL ❑GEOPOWSICAL WELL• f SOIL BORING- GCp rOJ1•L S <br /> ❑DESTRUCTION: <br /> INTENDED U[E TYPE OFWELL CONtTPVC710N�GECtPICAT-GNS A <br /> 11 INDUSTRIAL ❑OPEN BOTTOM Di A.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 0 <br /> 11DOMESTICRWIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING 0 <br /> (1 PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SFVCIFICATION R <br /> 13 IRRIGATION/AG El OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME E <br /> ❑MONITORING GROUT SEAL PUMPED:❑Yr ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y. ON. S <br /> APPROX.D[FTH LOCKING CHESTER BOX/STOVE P,FE ((--yy77 S <br /> PROPOSED CGNSTRUCTIOmm"LUMO METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHEFIL <br /> I HEREBY CERT47Y THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONF IN ACCORDANCE V41TH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGLMTIONS OF THE SAN JOAGUM COUNTY.NOME OWNER OR LICENSED AOEIT'S SIGNATURE CERTIFIES T14E FOUCVANG:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICII <br /> THIS PERMIT 19 ISSUED,1 SI TALL NOT EM PERSONS SUBJECT TO WORKMAN'[COM"IIATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR BUR-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWB" '1 CERTIFY THAT IN PEIlFO L ANCF OF THE WOR..FOR WHICH T/ FERMM IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CO PENIA OM LAWS OF <br /> CAUFOR:l1 T F Ari11CAN V[T t4 IIOLLit IR ADVANCE FOR ALL R[OURLEO 1 P[CTIO A71tOt14MJ423.COMPLETE DRAWINO AT LOWER AREA PAON D. <br /> s1aMd X J TIO 04 <br /> D•N <br /> PLOTH.A.ID,Z Le 1 6cdw 'to <br /> 1.NAMES OF STREFTB OR ROADS NEAREST TO OR BOUNDWO THE PPOI! 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On pnomSED <br /> 2.OUTLINE OF THE NJ OP£RTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTUNH.6 AND LOCATION OF ALL EXISTING AND PROPOSED t.LOCATPOH OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTUREINCLUDING CLUDING COVERED AREAS SUCN AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> 7 - <br /> Fo r.P,c civ T y f <br /> sm <br /> Z <br /> G r- l <br /> gS <br /> DEPARTMENT LICE ONLY <br /> APP9P•9on Acted By. <br /> GroU MI>Ktlen BN D•b p—IMP-v—13 D•Iw <br /> oe.111�uen In.n.aron By o•t. <br /> CemmeN•: <br /> ACCOlMTP4O oNt T:A_�` AID+ FACC <br /> P2 COOEt FE[INFO AMOI.MT RG'AITTED CHECKOUCA6H RECOVLO tY DARE ►ERSBT/iFAVICE R[OVfiT NVMSbt INVOIC[ <br /> Pub.Health Serv.-Enviro.173(3/96) <br />