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APPLICATION FOR WELL/PUMP PERMIT 0 � <br /> SAHEALTH <br /> ENVIRO MEN AL HEALTH DIVISION�� D <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> L U j �O1* PERMIT <br /> 468.3420 '� 11 <br /> V a/ WON-REFUNDABLE PENMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> (ComPIBR In Troci <br /> CAMPRICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT Al INSTALL THE WORL OESCMBED.THUS A N 16 MADE IN COMPLIANCE I18AN <br /> COUNTY DEVELOPMENT TITLE.CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVI <br /> CtN HEALTH DIVIBIONOg/-.Il / <br /> flE69/DR 9/��oq/ F/y Dr Ckn 4leufs SDCD.rPqC EL 6Iz ApNNAMEe >bN S 9 G 9 oB.el t�.e Y, i.2 Fr. <br /> t-/iTrJ ry�' y ADDREBB.FMP�y eii%/e !�O 9yeaf-/PJ7 PHONE I12O-L�Y-y GO <br /> CONT EN V I ADDRESS J Uc/ <br /> ,l1 { PHONE/ <br /> BUB CONTMCTOpy�eL+ Y'('L�en ADDRESS�f�y .{oil e,Q ?-5704r, UCICS7-S/��6➢ <br /> UPHONE I�'OY-Ste[ -D'. <br /> TYPE OF WELVPUMP; R NEW WELL ❑ REPLACEMEM WELL ICI MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTMCTON WELL/ J <br /> RYPE OF PIMPI ❑N.11 FillH,P. DEPTH PUMP 6ET_dAl FIRST WATER LEVEL 0 <br /> C1OUT-OF-SERVICE WELL 11GEOPHYSICAL WELL/ 11SOIL BOEING B <br /> 11 DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOMA <br /> ❑ DIA.OF WELL EXCAVATION /Q Fi DIA.OF CONDUCTOR CASING A/�,9/ O DOMESTICIIMIVATE ®GRAVEL PACK/SIZE � TYPE OF CASING/6TEEl/PVC_SCJ, yQ _Ply DIA.OF WELL CASING y.. <br /> O <br /> PIBLIC?AUNICIRAL ❑DRIVEN DEPTH OF GROIN SEAL S-0V SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY I]rill/• GROLR BRAND NAME Ad°a G1 Cell E <br /> ® MONITORING �J GROUT SEAL PIMPED: ®Y- [I N. ❑ <br /> Ne CONCRETE PEDESTAL BY 011 p,Ys Ne S <br /> APPROX.DEPTH A O LOCKING CHESTER BOXISTOVE PPEi <br /> T-' S <br /> PROPOSED CONSTRUCTION/DWLUNG METHOD: MUD ROTARY AIR ROTARY AUGERl CABLF OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION MO THAT THE WORK WILL BE DONE IN ACCORDANCE KITH SAN JOAQUIN COUNTY ORDINANCi STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TIRE FOLLOWING:'I CERTIFY THAT IN THE PEREORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENBAPON LAWS OF CALIFORNIA.- CONFRACTOR'9 HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PEASONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CA NIA.' THE APPLICANT MUST TCALL N HOURS IN ADVANCE FOR ALL FUGGUIRM I <br /> 1N <br /> �SPECTIONS AT I2OSI 4811 COMPLETE DRAWING AT LOWER AREA Fril ED. <br /> yj <br /> BI �/ .vlf, IJ�vR.a�o,� f7.v.IVJ/wa+/rin. }C 814i Pamir <br /> J j <br /> ROT PLAN IbnW In ell Si - <br /> 1. NAMES OF STREETS OR ROADS NEAREBT TO OR BOUNDING THE FTOPERrv. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On EFWPp6ED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> doe a — A3oxe AvJ116 <br /> DEPARTMENT USE ONLY '11 S`/`/•/f— <br /> iN ~Y 06 <br /> Appllce6en Ace«led By <br /> bele <br /> Oreul Irwv«Ven By <br /> O.'s I vR,le•P«Ileo BY Dele <br /> Onlnwllen Imo«lb By <br /> Dae <br /> Cemmmu: 110 Will, <br /> IF <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PEIp11TISFRVICE REQUEST NUMBER INVOICE <br /> Pub,Health Sew.-Enviro.173(1/97) <br />