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APPLICATION FOR WELL/PUMP PERMIT ©���3 �✓ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WESER AVENUE, STOCKTON, CA 95202 <br /> S S o 4 (209)468-3420 <br /> NON-REFUNDABLE PEAMIT EXPIRES i YEAR FROM pATE ISSUED "]'���JJJ�`���'1(,JpA]\ (CetmI In TrlpResb) dy <br /> APPLICATION IB HERE BY MADE TO THE BAN JOAOUIf�COUNTY FOR A pEN.tR TO CONSTRUCT <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF SANN JOAO N COUNTY PUBLIOR INSTALL THE C HEEA H SERVICES,RK DFrCRrg[O, +ENVIRONMENTAL HEALTH IN Dro ON COMPLIANCE WRH 9AN <br /> JOB AODREBMR APNff --Av8?—D�`' CITY-/ <br /> PARCEL 11 (- <br /> OWNER'S NAMEIll. <br /> CH � ADDfiE88 � �� G �PIIONE I/ <br /> CONTRACTOR //'' OO <br /> �lObF1ESB L1CIA /�PHONE <br /> SUB CONTRACTOR_ �� ADDRESS / uC1 � PHONE/ <br /> u <br /> TYPE OF WELLIPUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL R/ r ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAID <br /> -�j ❑ CRO88�ONNECt REP�R � ❑ VAPOR EXTRACTION WELL/ J <br /> New❑PAI H.P. h DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) ;k 0 <br /> ❑ OUT•OF-SERVICE WELL ❑ GE13POlYRJCAL WELL I ❑ SOIL BORING <br /> H <br /> I]DESTRUCTION: � ' <br /> INTENDED USE TYPE OF WELL CONSTRl1CT10N SPECIFICATIONS <br /> ❑ INDUSTRIAL OOPEN BOTTOM 01A.OF WELL EXCAVATION Z A <br /> OIA.OFCOHbUCTOflCA81NG <br /> MESTICA"IBVATEvw RAVEL PACKIME TYPE OF CASfNO/STEEL/PVC DIA.OF WELL CASING 0 <br /> //////❑ PURUCIMUN16PAL ❑ORNEN DEPTH OF GROUT SEAL SPECIFICATION CMG- a <br /> 1 IRRIGATICIII [:]OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑He <br /> ❑ MONITORING GROUT SEAL PUMPED:AYw OEBYAL BY DiiR1ER:❑Yr J S <br /> APPROX.DEPTH LOCKING CHESTER SOXWOVE PI_1 p / S <br /> PROPOSED CONSTRUCTTONMISLUNO METHOD: MUD ROTARY_ AIR ROTARY AUGER fI)�4 CABLE E <br /> ma <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORD APUIN ANCES,9TATE A RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES I AT LOF THE RK FOq WHICH <br /> THIS PERMIT IB ISSUED,I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COINF♦'SISATION LAWS OF C RNIA.l�T�CTCT N� �E B� H' L'IMBNATURE CERTIFEB <br /> THE FOLLOWING •1 CERTIFY THAT PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 10811E0,1 SHALL E IA'•�ep�-�- ��•r+i�r 0 ICtOT S N LAWS Of <br /> CALIFORNIA.. T MU HOURS IN ADVANCE FOR ALL REQUIRED INSM N8�1'I"In 4Ni4I3• COMPLETE ORA_ �R/(nREID- •( <br /> 9lpnod X Title .e' '�_ `� �ilat�,'�Y' <br /> PLOT FLAN ID•ow to Boolel Bede •to <br /> 1. NAMES OF 8TREET8 OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE O18POBAL SYSTEM OR P110POBEb <br /> 2. OUTLNE OF THE PROPERTY,OfVM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUI AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WNITIBN RAIM18 OF ONE HUNDRED FIFTY FT, <br /> BTAI/CTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> f . <br /> 1. ' I. <br /> A 1 <br /> APR: ...Z.1999 <br /> sari ;c,x�.icJlyd Gi:;,1tV� <br /> .,b ARTMVNT USE ONLY <br /> App#.otbn Aeeopted BY '��-'" Dote Aroo <br /> Ototo k»peotlen By O`Dote J C fJ Pump 4Npeellen BY Doh <br /> bwauetII impaction BY Dote <br /> CommeMo• t <br /> f-No <br /> *46,O <br /> ACCOUNTING ONLY: AIDI FACT 47 u- �r <br /> LL <br /> FE CODES FEE fNFO AMOUNT REMITTED CK/ ASH RECEIVED NY DATE PERMITlSERVICE REQUEST NUMBER INVOICE <br /> �- <br /> �Ieatth Serv.-Enviro.173(1/97) <br />