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r <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> �f SAN,wAOUIN COUNTY PUBLIC HEALTH SEF,,,�;ES <br /> -..,� ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NUN-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 11COMP6116 In I <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB AODRESS/oR APN/ jJ�/ <br /> O%Vwn'e NAME I t 41 G C CI��T77Y1 �A- PARCEL 81Z1AP1e'W1 rZ)Z <br /> ADDRESS G14L/ ��-y�� ,,�/�/l��7� <br /> CONTRACTOR�i �/ 1I,. �. ADDRESS G+C� RHONE/`TQ/ )60 <br /> I <br /> "��• LRC;F <br /> RUB CONTRACTOR � � z <br /> ,�/ ,�/ ADDRESS E�71 PHOTJe7'- <br /> TYPE OF yYELLIPUMP' LSYNEW WELL C� REPLACEMENT WELL Lt1 MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> ❑New❑Rapelt H.P. J <br /> (TYPE OF PVMPf DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> C1OUT-0F-SERVIC !, <br /> E WELL ❑ OEOPHYMCAL WELL N -SOIL BOR]NG�«1-e^ e <br /> ❑DESTRUCTION- <br /> INTENDED USE TYPE OF WELL CONSTRUCT]ON iPECIFICAT10Na <br /> ❑ INDUSTRIAL ❑OPEN BOTTGM DIA.OF WELL EXCAVATION 1 (!i <br /> T� A p��J DIA,OF CONDUCTOR CASING <br /> DpMESTICNPRIVATE yJ GRAVEL PAC1(lBIZF�V� TYPE OF CABIN[;ISTEE <br /> ❑ PUBUC7MUNICIPAL ❑DRIVEN DIA.OF WELL CASINO --2,7 <br /> O <br /> DEPTH OF GROUT 6EAl ��^ � ,,ECIFK;ATItlN 1 <br /> ❑ IRRIGATIONIAG ❑OTHER 4''— A <br /> E�// GROUT REAL INSTALLED BY t--t� GROUT BRAND NAME <br /> LL'MONRTORlHG _ GROUT SEAL PUMPED: ❑Vr l7aTTo _Z� E <br /> APPROX.DEPTH_ C.1 �!� CONCRETE PEDESTAL 9Y DRILLER;Ely. ❑Ne S <br /> -- LOCKING CHESTER pOXMTOvE PIPE_ <br /> PROPOSED CONSTRUCTIORMAILLINO METHOD: MUD ROTARYE S <br /> AIR ROTARY AUGEq_��CABLE OCHER <br /> 1 HMSY CERTIFY THAT I HAVE PREPARED TH18 APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AHO RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTRY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE E THE WOO(TOR WHICH <br /> TF]t8 PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOPKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE POLLOWINO; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUINED INSPEOTIONG AT 1129914"4423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slpned X fit� Title <br /> Date �,ti <br /> PLOT PLAN lbtwv to Sodel Bosfe 'to <br /> T. NAMES OF STREET@ OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE BFWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM@, <br /> G. DIMENSIONED OUTTJNF.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS%WrNIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURE@,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. <br /> MAY4 1998 <br /> - <br /> QA <br /> : <br /> OMNI; 3JTR.HEALTH <br /> �NViR {�S . <br /> D ? !ON <br /> t <br /> D DEPARTMENT USE ONLY f`' <br /> "cwtten Aeeepted BY "��}`" Data, -�'{ A— <br /> Grout hhpwtbn By - Date Pimp Impaction By Date <br /> D"IftftHen lmpmtlon Sy <br /> Dote <br /> Comments: <br /> ACCOLIHTINO ONLY. AID# FACR <br /> PE CODES FEE INFO AMOUNT REMITTED CNECKIICASH RECEIVED BY DATE P011MITI@ERVICE REQUEST NUMBER INVOICE <br /> Pub.Health Serv.-Enviro.173(1/97) <br />