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600lfl <br />APPLICATION FOR WELLIPUMP IT <br />SAN JOAQUIN COUNTY PUBLIC HEALOSIERVICES 0 0 0/ `72 - <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. 13OX M 304 FAST WEBER AVENUE, STOCKTON. CA 9MIMa <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete In Trilillents) <br />APPLICATION 18 14CAE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WIT11 SAN <br />ACCOUNTING ONLY: AID# <br />JOAQUIN COUNTY DEVELOPMENT TIT APT 5.3 AND TtqE STANDA 9 OF AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADORESSMR APN# =c,,, 77(A/ r 7 4 <br />� <br />PE CODER FEE INFO <br />PARCEL SIZEIAMI <br />OWNER'S NAME EQ ® A r f) --Tyii ADDRESS A Aq(&- PtIONE 0 <br />INVOICE <br />CONTRACTOR CLAAK A z Lz—t L, �-CAd �#47Y <br />2 2 <br />UC#:3�716 PHONE <br />OUR CONTRACTOR ADDRESS Lice PHONE 9— <br />TYPE OF WELLIPUMM RNEW WELL El REPLACEMENT WELL 0 MONITORING WELL 13 OTHER <br />11 INSTALLATION [I WELL SYSTEM REPAIR 11 CROSS -CONNECT REPAIR 11 VAPOR EXTRACTION WELL <br />1, 11 New El Repair H.P. DEPTH PUMP SET <br />FT. FIRST WATER LEVEL <br />(TYPE OF PUMP)❑ 0 <br />ou-t-or-sERvicE WELL ❑ GEOPHYSICAL WELL BOIL BORING <br />❑ DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION $ PFC IFIC �ATI 0ff A <br />0 INDUSTRIAL 0 2-0 <br />OPEN aorrom 2-1 DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING 41119 <br />- <br />11 DOMESTICIPRIVATE &GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC <br />J DIA. OF WELL CASING n <br />11 PUBLIC/MUNICIPAL DRIVEN <br />SPECIFICATION R <br />DEPTH OF GROUT SEAL C1 ( <br />Q ldfif <br />10 IRRIGATION/AG ❑ OTHER <br />GROUT SEAL INSTALLED BY GROUT BRAND NAM E <br />11 MONITORING <br />�,. <br />GROUT SEAL PUMPED- e. 01 CONCRETE PEDESTAL BY DRILLER: 0 No s <br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED COKSTRUCTIONIDAILUN. MffrMlll: _MUD AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I IIAVIE PREPARED THIS APPtJCAT+dW AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. <br />HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: *1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br />T"18 PERMIT 16 ISSUED, 1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' <br />CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: * I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR W041CH THIS PERMIT 10 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />fi <br />CALIFORNIA.' TV <br />*T LL 24 ROUFIS IN ADVANCE FOR ALL REQUIRED INS$ AT 12001400 -V22- COMPLETER <br />DRAWING AT LOWER AREA PROVIDED. <br />,a <br />Stoned X Title el 441,1,( <br />Date <br />PLOT PLAN (Draw to goals$ Scale— * to <br />T. NAMV OF STREETS OR ROADS NEAREST TO OR BOUNDING THE OROPEM. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3- 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 nn All-InINain Mnocmn— <br />M <br />Ovir <br />96- <br />-1:30) C, dA trot <br />N <br />0 L /101 <br />7-/74 AroeeA <br />Data <br />Date <br />Pub. Health Serv. - Enviro. 173 (3/96) <br />ACCOUNTING ONLY: AID# <br />FACN <br />PE CODER FEE INFO <br />AMOUNT REMITTED _C"`ECK1)CAS" RECEIVED By DATE PERMIT/SERVICE ne GUEST NUMBER <br />INVOICE <br />W3 05,c)_ <br />2 2 <br />0330 -A.Q <br />Pub. Health Serv. - Enviro. 173 (3/96) <br />