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APPLICATION FOR WELUPUMP PERMIT �E <br /> S AQUIN COUNTY PUBLIC HEALTH S*CES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> kICATPERMIT <br /> 468-3420 ORIGINAL <br /> WON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> RE BY MADE TO THE SAN JOAOUIN COUNTY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMFIT'DEVELOPMENT TREE;CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTYPUBLICHEALTH SERVICES,ENVIRONMENTAL HEALTHPNS _ CITY /AL7�N PARCEL BIZ APN � f Vy <br /> w 5y� S' : /.. T •.l. ADDRESS E�ADUPEBS LICE PHONE E <br /> b/d0 eQe1 dA A <br /> BUB CONTRAcrOR i ADDRESS SeSG��11rg9-VV72 IIDEL-S7•/7768/ PIONEE707-8d.S-J <br /> TYPE OF WELL/PUMP: 10 NEW WELL ❑ REPLACEMENT WELL NI MONITORING WELL E ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR08S-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLE <br /> /v A' ❑New 11R.P.Ir H.P. DEPTH PUMP SET�,ET. FIRST WATER LEVEL p <br /> pVPE O PUMPER <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELLE ❑ BCR BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 3 A <br /> 11 INDUSTRIAL ❑�AA OPEN BOTTOM # DIA.OF WELL EXCAVATION /OS/y " DIA.OF CONDUCTOR CASING / 7 <br /> L1DDMESTICR'EBVATE 0GRAVEL PACK/SIZE K9 IO TYPE OF CASINGISTEEIR'Vd'311A D PYC DIA.OF WELL CASING �� G <br /> ❑ PUBLICRAUNICIPAL ❑DPVEN DEPTH OF GROUT SEAL / / SPECIFICATION R <br /> 11 IRRIGATIONIAG ❑OTHER GROW SEAL rRTX <br /> yy <br /> INSTALLED BY Z1-1I/e/- GROUT SRANO NAME NPR/- Ce» CM e E <br /> MONITORING '7 GROUT SEAL PIMPED: pa Y« ❑Ne CONCRETE PEDESTAL BY DRILLER:®Yw [IN. 5 <br /> APPROX.DEPTH /0(O LOCKING CHESTER BOXISTOVE PIPEjeS S <br /> PROPOSED CONBTRUCHONR)PoWNO METHOD: MUD ROTARY AIR POTARY AUGER CABLE OTHER <br /> I HEREBY CERTIEY TIHAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANC <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE W w FOR MAIICF <br /> THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CA IA.' THE APPUCANT MUST CALL 28 HOURS IN ADVANCE FOR ALL REQUIRED INSPECHONA AT 120N 4888422, COMPLETE p WING AT LOWER AREA PROVIDED. <br /> PLOT PLAN 0I.w to Bari 6c.1. 'I. <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE POPRTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE POPERTYOR ADJOINING PROPERTY. <br /> M Rp )qf� QC,� eOL <br /> oc- o20— /y /Z/l .....F ' <br /> DEPARTMENT USE ONLY <br /> A ,k.Don A..wtm By EINE Nr <br /> G,..ImPxlloe By DNe RPP In.Patlen by Daa <br /> O«bmtlen bwP«ibn By D.t. <br /> Demmer,,.: �,�^-e- 7b= /�/ 1�t<..✓- 1/ <br /> ACCOUNTING ONLY: NDE FAC! <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKEICASN RECEIVED SY DATE, POWITISERVICE REGUEST NUMBER INVOICE <br /> 2 0/ 2 <br /> Pub.Health SEN.-Envire.173(1/97) <br />