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I � . <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> • (209) 469.3420 <br /> NOR-REFUROABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Trlplketel <br /> APPLICATION IB HEW BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORL DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT BAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.3 AND <br /> THE STANDARDS OF SAN JOAOUIN COUUNNTY'PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. �F <br /> JOB ADDRESB/On AM# �I11G OI h 4g, 4. <br /> CTI C..k�h PARCEL SIZEMPN/ <br /> OWNEn'e NAME tnG aFY Gleanfn} DC fcrLdµLFs di0 ADDRESS(ROD (well,5�' 2H-.l: r�,�wE w,wille NE4�,�5a-L(SOD <br /> rn+'1 Br4d3h41vP 1-ojcc} µ�awt4 - <br /> FfiCC-- <br /> SUBCONTRACTOR ApOnEee�e�E� W C <br /> r- a ___AM PNe.ie wr- <br /> TYPE OF WELIJPUMP: ❑ NEW WELL REPLACEMENT WELL ❑ MONITORING WELL# TSSA OTIIEM�P h ro <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑ <br /> RYPE OF PUMP) N.11 Reptl, H.P. DEPTH PIMP BEI_FT. FIRST WATER LEVEL G <br /> ❑ DVT-OF-SERVICE WELT. ❑ GEOPHYSICAL WELL/ 11 BOIL BORING R <br /> VDESTRUCTION: TM'etvtl'C Por`+farad 4evp%o.n+-- Be►Lfoail-G &I-OLt ')"— <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INOUSTMAL ❑OPEN BOTTOM DIA.OF WELLOCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ OOMESTICMOVATE ❑ORAVEL PACK/BRE TYPE OF CASINOMTEEL/PVC DIA.OF WELL CASINO D <br /> ❑ PIBUCrMUMCIPAL ❑DRIVEN DEPTH OF SMUT SEAL SPECIFICATION R <br /> ❑ IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME E <br /> ❑ MONITORING1 GROUT SEAL PUMPED: ❑Yee 0H CONCRETE PEDESTAL BYORIUIEl yr ❑Ne S <br /> APPROX.DMH top'T <br /> LOCXNG CHESTER Boxiwo ERPE <br /> S <br /> PROPOSED CONSTRVCTIONIDRILUNG MUMD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER_P <br /> 1"May CERTIFY THAT I IIAW PREPARED THIS APPLICATION AND THAT THE WOR(W RL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> GIMTIONe OF THE BAN JOAWIN COVNTY. HOME OWNER Oq LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE MW FOR WHICH <br /> WIB PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CEITFIFIEB <br /> HE FOLLOWINO: •1 CERTIFY THAT N THE PERFORMANCE OF THE WOOS(FOR WHICH THIS PERMIT IB ISSUED,18HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORNIA: T CANT MUST <br /> CALL Z4 HOURS IN ADVANCE F1OR/A`LL MODIFIED INSPECTIONS AT 12")400J 22. COMPLETE DRAWING AT LOWER AREA FRONDED. <br /> � elEmd X \ <br /> Gfiec� GItp1yGFFI/S PUNto,.1.1.0Be.l.I•INc{{ <e oo F«? <br /> 1. NAMES OF STREFTB OR ROADS NEAREST TO OR BOUNDING THE P OPITITY. 4. LOCATION OF HOUSE SEWAGE OIBPOBAL SYSTEM On PROPOSED <br /> Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NOW"DIRECTION. EXPANSION OF SEWAGE DISPOSAL 9YBTEMB. <br /> 3. DIMENSIONED OWLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WAL(S. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> R RO\ 9� <br /> /Norge �� Mwla \ <br /> Gleaning Who q, <br /> nTTl$Dmt xa <br /> a <br /> W100 MwlOe. <br /> WIT <br /> ' <br /> AI <br /> Cheymn <br /> GazSIaIi00 MW3 E <br /> r- <br /> pVEYN C PT- 10 0 <br /> MWI$, MW-6 Q,ICVC <br /> MW-7 <br /> m.GaS StauDn <br /> amedy Regal LINCOLN CENTER,STOCKTC <br /> A Wickland) <br /> Figure 3: <br /> PROPOSED SVE,AIR SMR <br /> AQUIFER W MONRORING <br /> P pdbaM I_EVIII/\/L/��I/�7� DEPARTMENT USE ONLY <br /> ApPlbellen Ameyled By_ l_P t bele II A e <br /> Greet Impeetlee By DNe Pump Impmlbn Ry OHe <br /> oeeourtlen lnepeellen Sy net. <br /> Cemmernc <br /> ACCOUNTING ONLY: AX)/ FAC# <br /> PE CODES FEE INFO AMOUNT SUMMED CHECKIMASH RECOVEp BY DATE PERNOTISERVICE REQUEST NUMBER INVOICE <br /> 2 (� D I pgoq <br /> Pub.Health Sew.-Enviro.173(3/96) <br />