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APPLICATION FOR WELL/PUMP PERMIT <br /> SANdWQUIN COUNTY PUBLIC HEALTH SEES <br /> NVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 60 <br /> (209) 468-3420 <br /> RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ORIGINAL <br /> APPLICATION IS HERE BY MAGE i0 THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONST UCTIAND/OBTrIplI INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE Wrt11SAN <br /> JOAQUIN COUNTY DEVELOPMENT TI/TLE;CHAPTER//BJJ-1115//.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APNIj3z_y �iA/CG)yJ ( P rf(— CITY�JTD(t�� 300,Wp4914--ate/0. <br /> � D•'N R�QR,,,u,2 De/G•e eCwµ� (Sb-bi PARCEL BIZE/APNIOI <br /> OWNER'S NAMEC T LKrgi /400 p01UC11 S7' /� /-/OOr <br /> R ON ADDRE68_F=p� r,L DRONER 410-(.S-.?'yJaO <br /> CONTRACTOR <br /> ADDRESS LIC& PHONE/ <br /> SUB CONTRACTOR 9rfa0 -S'fU T OWC: Cog <br /> nbpn6.eMa r_Y:N7y C.'�1 9ySS3 uc& (aSGY07 PHONE&S�o-3iS-SEDC <br /> TYPE OF WEII/PI1MP ❑ NEW WELL ❑ BEPLACEMEW WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECTIMPAIR ❑ VAPOR EXTRACTION WELL <br /> R VPE—OFMMPI <br /> 11 Hew H.P. DEPTH UMP SET FT. FIRST WATER LEVEL 0 <br /> ❑ OW-OF SERVICE WELL ❑ GEOPHYSICAL WELL& ® BOIL BORING O <br /> DESTRUCTION: <br /> B <br /> INTEND.0 USE TYPE OF WELL CONSTRUCTION 6PECIFICATIONt <br /> ❑ INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION .9- "es DIA.OF CONDUCTOR CASING A1117A <br /> ❑ DOMESTICINIVATE El GRAVEL PACK/SIZE TYPE OF CASINGRTEELRVC- eda DIA.OF WELL CASING_ <br /> U ��� D <br /> ❑ BIM <br /> LICUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL �'O�i]1 rJ PYJ f'� SPECIFICATION <br /> El IRRIGATION/AO ®OTHER GROUT SEAL INSTALLED BY PO T'Q, fOr" GROW BRAND NAME_ N�G7 _ile A <br /> ❑ <br /> MONITORING E <br /> / GROUT SEAL LIMPED: Dd IME ❑1s CONCRETE PEDESTAL BV DRILLER:❑yw []N. ,VIA 6 <br /> APPROX.DEPTH �� Z410 Q <br /> LOCKING CHIMER BOX/STOVE PPE _ <br /> PROP)6FD CONSTRIICRON/DRIlLINO METHOD; MVD ROTARY ! S <br /> AIR ROTARY AUGER CABLE OTHER 0./Y / <br /> ?u.c <br /> 1 HEREBY CEFTEITY THAT 1 HAVE PREPAREO THIS APPLICATION AND THAT THE WOIK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE.,STATE LAWS,AND BULL.AND <br /> REGULATION.OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AD ENT'.SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFONMANCE OF THE VWw FOR WHICH <br /> THIS PERMIT IR ISSUED,I SHAM HOT EMPDY PERSONS SUBJECT TO WORKMAN{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR-9 HIRING OR 6U"ONTRACTUNG SIGNATURE CERTIFIES <br /> THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THEW OW FOR WHICH THIS PEEWIT I.ISSUED, <br /> CAUFORNIA.' THE A1 SHALLMPLOY FEPSONB SUBJECT TO WORKMAN-11 COMPENSATION LAW.OF <br /> APPLICANT MUST CALL 31 HOURS IN ADVANCE FOR ALL REOWED INSPECTIONS AT IMSI IStsLEMPLOY <br /> COMPLETE DRAWING AT LOWER AREA r�nN-11 COED. p <br /> elpnedx4j.y� jL TRIS Site �r'O iPIT Manlaa FlyD. <br /> 1. NAMES OF STREET.OR ROAD.NEAREST TO OR ROUNDINGT HEMP OPERTY. ec.le •Ip <br /> t. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> D. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF BEWAOE DISPOBAL AYSTEMB. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIO.,DRIVEWAYS,AND WAIKe. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY ET. <br /> ON THE PROPERTY OR ADJOINING pROPERry. <br /> " JRp 17ft//0. a� ec(, <br /> DEPARTMENT USE ONLY rrry•���� <br /> Applleellen Aeeepted 0y �P OWv r/ <br /> b.a U <br /> Oroul lnepxllen By <br /> D•R° Pump ImpxOen By <br /> D.R. <br /> Dea„..nen In.necnen ey <br /> Cemmdnc , /Dlele�ArJ'-/� �Q <br /> � - g- -c.�•rr�.ccF 9�f- F — <br /> ACCOUNTING ONLY: AID/ <br /> FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKI/CABH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> ?Rv 359 CTL- 7-rY-?S <br /> O 0 <br /> Pub.Health SEN.-Enviro.173(1/97) <br />