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•PLICATION FOR WELL/PUMP PERMI# SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES op/' ENVIRONMENTAL HEALTH DIVISION 4,01 304 EAST WEBER AVENUE, STOCKTON, CA 95202 O (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compkt•M Trkikofol APPLICATMN 16 NEM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRICT AND/OR INSTALL THE PARK DESCRIBED.THIS APPUCATION 16 MADE IN COMPLIANCE WFIN SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 5-1115.3 AND THE STANDARDS OF SAN"AWN COUNTY PUBUIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADURESSMA APNI 14253 S . AIRPORT WAY CTMANTECA, CA 95336 PARCELSQUAPN11 98-03-04 OWNER'S NAME ('_ TIF. rRonT $ gc)TYTS �p —ADORE9e QnR RTTRV rT FRTPnM rA PMw#909-471 -1787 CONTRACTOR VRW T)RTT,T,TNC TNC_ ADOHE68Pn Rn)( 51 m#7?ngn4 PHDNE'107.274 B-1 5 SVS CONTRACTOR AC@PM@ RIO VISTA, CA tMWO.V q 4 5 7 1 PHONE I TYPE OF WELL/PUMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CFMSS-0DNNKT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑N.13 P• . N.P. DEPTH PIMP BET—FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-0E-BERVCE WELL ❑ GEOPHYSICAL WELL I R SOIL BORING� B ❑DEBTADcTION: CLOSE BORING WITH NEAT CEMENT ROT AFTER SAM .TNG INTENDED USE TYPE OF WELL CONSTRUCTION SPKUICATIONS A ❑ INIMITIBAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 0 ❑ OOMESTC6 VATE ❑ARAM PACK/SIZE TYPE OF CASINORTEEI/PVC DIA.OF WELL CASINO 0 ❑ PusuctMUNCNAL ❑DRIVEN DEPTH OF GROUT REAL SPECIFICATMN R ❑ MOATION/AG ❑OTHER OROVF BEAL RIBTALIEU BY GROUT BRAND NAME E ❑ MONITORING GROUT BEAT PUMMO: ❑Y. ❑N• CONCRETE PEDESTAL SY DRILLER:❑Y. ❑N. 5 APPROX.DEPTH LOCKMG CHESTER BOXISTOVE PPE 5 PROPGSW CONSTRUCTOWDRILING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER CF..nPRo E I HERI:AY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE N ACCORDANCE WITH SAN"AMIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTRES THE MULOWINO:'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 KIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATMN LAWS OF CALIFORNIA.- CONTRACTOMB MAINS OR W"ONTRACTNO SMNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WNKH THIS KAMTI IS MOVED.1 SHALL EMPLOY PERSONS SUBJECT TO WORMNAM'S COMPENSATION LAWS OF CALIFORNIA.- THIS APPLICANT MUST A 71 fIOUIU IN ADVANCE FOR ALL REQUIRED WSKCT12 ON/AT W1 SpAN21. COMPLETE DRAWING AT LOWER AREA RDVIOED. 81P—t X C ^' LL lt.' Tn. �', DN. PLOT PUN IN.w Ie Se•I.1 Be•I. 'ro 1. NAME@ OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PIOMMU 2. OUTLINE OF THE RMPERTY,OMFM DMENBIONS AND NORTH OSECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. B. DMENSIOWD OUTWE6 ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS NTIIM RADIUS OF ONE HUNDRED FIFTY FT. BTRUCTUREB,WCLUOING COVERED AREAS SUCH AS PATIOS,ORVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOIWW PROPERTY. 1 7 .... ........ DEPMTMENT USE ONLY nppn.lbn AewP1eE BY D.1. /.___________''C�L711� IwKIJ 4/J OrvU xvPe•rbo Br 1 D•Is Pvnv Imvectlon BY SIN+v�r� +�.r— Osbrellen Imn.lbn er T D•ay� •• '/v/w, �— Cemmsrl•: /L1� A _ ACCOUNTINO ONLY: AID# FACE PE CODES FEE INFO AMMMIT MNSTTED CIIECKIMASH RECEIVED BY DATE PSWITISEAVICE REQUEST NLMwR, INVOICE -67 Z Pub Health Serv.-Enviro.173("7)