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1P QUIN CON FOR WELL/PUMP PERMI'SAWAQUIN COUNTf PUBLIC HEALTH SEESCO!5 <br /> ENVIRONMENTAi.hcALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED O G I <br /> RI <br /> APPLICATION IS Y DE EL MADE TO THE SAN JOAOHIN COUNTY FOR A PERMIT TO CONSTRUCTIANDIroq <br /> INSTALL THE WOW DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WITiI SAN <br /> JOAOVIN COUNTY DEVELOPMENT THIS;CHAPTER#-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OII6ION. <br /> JOB AODRESSMR APNI G "� �/ y �P ITo <br /> se>S�G <br /> . , -. CITY J1GL <br /> OWNER'S NAME ne7 F/r PAKELSQUANImD�Ne, _ <br /> T P ADOAE6B�e'el Pr- J //Py� q(/LOR /P���pNDNE a�/Q <br /> CONTRACTOR I 6 .T S'JOO <br /> ADDRESS Mo PHONE <br /> BVD CONTRACTOR /1 (1700 fl K O OJ S0. <br /> I��,11 ADonesB Se 6A ,oe 1 T p 9-16_2 ucl C-T2_07681 PHONE 12 07- -73-3i.0Y <br /> TYPE OF WELUPUMP; IO NEW WELL ❑ PEPACEMEM WELL Y11 MONITORING WELL <br /> OTHER <br /> nn ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ <br /> N'T ❑New❑Repar N,p, 11 VAPOR <br /> AIroR E%TRACTION WELL/ <br /> RYPE O POMPI DEPTH PUMP GET FT. FIRST WATER LEVEL _ <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING 0 <br /> OE6TflUCTION: <br /> B <br /> om <br /> INTENDED USE TYPE OF WELL CONbTRUC/10N 6PECIFICAiIONb <br /> ❑ INDUSTRIAL �❑�AA OPEN BOTTOM q DIA.OF WELL EXCAVATION - / DIA.OF CONDUCTOR CASING /73/� e A <br /> ❑ DOMEBTIC/1`NVgTE NI GRAVEL PACKISIZE K (O TYPE OF CABIMUUFELA'VC�(J1p/i/0 PVC DIA.OF WELL CASING 7 D <br /> Cl P/BLICRAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL / D <br /> ❑ IRRIOATIONIAG T SPECIFICATIONK� OTHER GROUSE <br /> T AL INSTALLED R <br /> HD%%BY `I-�F�I Isla r ONOUT DRANO NAME NCR7' e!° <br /> W yN <br /> MONITORING GROUT SEAL PUMPED: Yee Cl N. CONCRETEPEDESTALBYDWLLER:®Ys (IN. 5 <br /> APPROX.DEPTH_ LOCKING CHESTER BOXIUOVE PPE <br /> PROPOSED CONSTRUCTION/gEWNG METIOD: MUD ROTARY AIR ROTARYS <br /> AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT 1 IIAVE PTIEPAREO THIS APFLICATNON AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN"A IN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGEM'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR MUCH <br /> THIS PERMIT IB ISSUED,I SHALL Not EMPLOY PERSONS#OBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 IBSVED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 2//OURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001 4"3 22, COMPETE DRAWING AT LOWER AREA PROVIDED. Q11R <br /> Blamd%�f ... Till. VI/ G Pr0•L <br /> 6eele • <br /> I. NAMES OF STREETS <br /> PR OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br /> not PAN(Drew to Ike.] to <br /> S. OUTLINE OF Tiff POPRTY,GIVING DIMENSION I AND NORTH DIRECTION. /. LOCATION OF HOUSE SEWAGE MRPOSAL SYSTEM On PROPOSED <br /> 3. DIMEN6IUNED OU'LINE6 AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE D18MSAL SYSTEMS. <br /> GTRVCTURE6,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AM WALKS. C LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED HFTY FT. <br /> ON THE PROPERTY OR ADJOINING POPgTY. <br /> MOP <br /> OEPARTMENT USE ONLY <br /> APPIICeIIen Aeeepled By ( ZD -9 U / <br /> Grein ImPectlen BY Dem <br /> 6y Dae <br /> De.bfcsen Imne/�U/�e1/n�ey {' <br /> Gemma,m:_ �g ItiI <br /> lM- <br /> ACCOUNTING ONLY: AID/ FACT /C <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE <br /> PHENITIFFRVICE REQUEST NUMBER INVOICE <br /> Pub,Health Sew.-Enviro.173(1/97) <br />