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SA*°PPLICATION F/1R "'-!L,/PUMP PERMI— C <br /> AOUIN COUNTY PUBLIC HEALTH SEDES 5 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> ZION-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED1CORI0 R I G <br /> n Tripnestal @f <br /> APRICATION IS IIERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTP UCT16112 IANOM"INSTALL THE WOR(DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE NRTII SAN <br /> JOAOUIN COUNTY DEVELOPMENT TRLE��� <br /> ;CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH IN COMP. p <br /> JOB AODMSS/ORAPN/ .3�� ,L Ctn, s ON TVISION <br /> JP ClPARCEL SIZUAPU/��v POW41ER'S NAME C/ S y � /960 6Rl fel �f C /qT , ��P <br /> ADDRESS &M� PHONEI�6.6SeD•S�SOO <br /> CONTRACTOR <br /> ADDRESS UC/ PHONE/ <br /> sue CONTRACTORS <br /> �I1 AoolRFse Se�.oe 1 pp y rYJ� uc/C'S7•/77681 PHONE 1707-BJ3.3/py <br /> TYPE OF WELL/FUMP: 10 NEW WELL ❑ REPLACEMENT WELL pl MONITORING WELL/ ❑ OTHER <br /> n MPI ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> RYPE O PU <br /> NTT ❑New 11P,.,, N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> DESTRUCTION- J <br /> O <br /> ❑ OVT-0F6FRVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOK 80RIN0 <br /> B <br /> ❑ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIfICATIONS <br /> ❑ INDUSTRIAL 6❑1 OPEN BOTTOM ift,g DIA.OF WELL EXCAVATION _ / �O's�S� DIA.OF CONDUCTOR CASING 73/� • A <br /> ❑ DOMESTICA`W VATE ICI GRAVEL PACKRIME M 69 TYPE OF CASINO/6TEEVPvd!29=6 �✓0 P/�C DIA.OF WELL CASINO �� B <br /> ❑ "LICMUNICIPQ ❑DRIVEN DEPTH OF GROUL SEAL 210, SPECIFICATION O <br /> ❑q IRRIGATIOWAG 11 OTHER GROUT SEAL INSTALLED BY Zr—;Me GROUT BRAND NAME NCR f C Ye'1 eyZ� E <br /> Ip MONITORING '7 GROUT SEAL PUMPED: Od Y. [IN. CONCRETEPEDESTQBYORILLER:®Y« ❑N. 5 <br /> APPROX.DEPTH_ /IX O LOCKING CHESTER BOX/STOVE PPEu` <br /> S <br /> PROPOSED CON/ R <br /> IAULTHONIDLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> — <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE YA)IK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE UWe,ANO RULER AND <br /> REGULATIONS OF THE SAN JOADUIN COUNTY, HOME OWNER OR LICFN6E0 AGEM'S SIGNATURE CERTIFIES THE FOLLOVANO:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT KB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBLOMRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED.I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEnt TION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL_ 24 HORS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT ItM14uJ 1111.. COMPLETE DRAWING AT LOVER AREA PRONGED. <br /> eta x \� _ .�i': { TIG. J//`C nor PUN 0.to%w.I U.l. <br /> V"I-tl•i Nn.D` /'/Q�VaariJ— Dn._j�'.,..f.�.,..•�.. <br /> •le V U <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROURMNO THE PROPERTYY, 4. LOCATION OF HOUSE BEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 7. OUTLINE OF TILE PIOPEHTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL eY8TEM8. - <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELL8 WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRI VEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> M R pftQ <br /> 1 <br /> DEPARTMENT USE ONLY <br /> APPlIc.11en Accepted BY /•��} �7 g (J/_ <br /> O'"Imp«Sen BY D.l. Rmp IO.P«Sen BY <br /> D.Ie <br /> De.bwllen Imp«Ibn ev <br /> ACCOUNTING ONLY: AID/ FAQ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE <br /> PEIEMT/SFAVICE REQUEST NUMBER INVOICE <br /> 90 S iv ICY <br /> Pub.Health SEN.-Enviro.173(1/97) <br /> �o <br />