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APPLICATION FOR WELLJPUMP PERMIT <br /> A .t. SAIWOUIN COUNTY PUBLIC HEALTH SEES <br /> NVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T.� *r� <br /> (Complete In Troncobl rt `y <br /> APPLICATION IS HEM BY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT ANDMR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WryII SAN <br /> JOAQUIN COUNTY DEVELOPMENT T/RLE;CHAPTER/9-1115/.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH Q U,DN. n l/ <br /> JOB ADDRESS/OA APJI,37y y�i N�OIN ( IIF(- Cm,����� .Z SOT/(/.a 93. 4k1� <br /> PARCEL SQUAPNI CW (-F )[ y. <br /> ry a a.A/� (SbG PaWGII Sf /� F/oP� <br /> OWNER'S NAMEC/ D�+ R)e ,�.n L92�'� IF4 Aero ADDRESSE.«o�ti�//.p,_, C/Q 9y608-/8A� pHONEI /0'/eJ.?' <br /> CONTRACTOR J YJ�Q <br /> ADDRESS LX:I PHONE I <br /> SUB CONTRACTOROWC CC- <br /> ADbnE6BMp/Y;tipT C.5 5"'T6-3 UC. �-JLJ0 PHONEI6/O <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I— IJ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> J <br /> New❑Rap.b N.P. <br /> (TYPE OF PVMPI DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑ O <br /> 11 DESTRUCTION: OUT-OF-URVICE WELL 11 GEOPHYSICAL WELL I ® BOIL BONITO <br /> B <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIGH4 <br /> ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION ,,-Y.,O"p5 DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTICA'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL C A/IA DIA.OF WELL CASINO A/��C] /// R <br /> ❑ NBUC/MUNICWAL ❑ RI <br /> DRIVEN DEPTH OF GROUT SEAL �'O�i1/ !Jp f� SPECIFICATION_CI 11<lMI I- <br /> 11 mRIOATION/AG ®OTHER GROUT SEAL INSTALLED BY QQ FZO. 7<OI-" GROUT BRAND NAME NI/7 E <br /> 11MONITORING GROUT REAL PIMPED: ®Y. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y« ❑Ne A/IA S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE A/ZR <br /> / 5 <br /> PROPOSED COHSTRIICNONROPWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER LAY IC �uS/j <br /> 1 HEREBY CERTIFY THAT 1 NAVE PREPARED THIS APPUCATON AND THAT THE WORK MALL BE DONE IN ACCORDANCE WITH SANJOAOUIN COVIRY ORDINANCES,STATE LAWS.AND gUlEe AND <br /> REGULATIONS OF THE SAN"AMIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF TILE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WOR MAN'S COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'S HIRING OR 81)BCONTRACTING PONATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.-.- THE APPLICANTNT�MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED IINSIMP TIO;N11 AT 12081/4«,111121. COMPLETE DRAWING AT LOWER AREA PROVIDED. p p <br /> BIIMxd X--4•L_f�d�/J1_ A- Fm— Title <br /> POT PAN(M.w le S Wttl Sp.l. 'ro <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PORb6ED <br /> 2. OUTLINE OF THE PROPERTY,GIVING"'It"11018 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISMOAL SYSTEMS, <br /> 2. DIMENSIONED OVTUNES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUHOr1ED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY TY OR ADJOINING PNOPERTY- <br /> i <br /> M -9P �1ftQ ��, ccc <br /> ......................... <br /> ApplluDEPARTMENT USE ONLY 9 9� <br /> een Acpepled BY / � // Dw / <br /> Get. <br /> Oreo1 ImpaUen By D.Ie P P I..Patlen By <br /> DH. <br /> D«<nnaen Impatlon By <br /> D.I. <br /> Demmer,,.. ,lix_ —fit 32 <br /> ACCOUNTING ONLY: - AID( FACE <br /> ZJ <br /> PE CODES FEE INTO AMOUNT REMITTED CHFCKIMABH RECOVED BY DATE <br /> Z O PERMIT/SERVICE REQUEST NUMBER NVOICE <br /> 3 60o c «- -2 a <br /> Pub.Health Sew.-Enviro.173(1/97) <br />