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WAQLICATION FOR WELPUMP PERMS SAN UIN COUNTY�UBLIC HEALTH SER ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 FILE COP Y (209) 468-3420 RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICBmpIEEE M TRIpRaIEI APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PEEWIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.Title APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPIAENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAM"AMIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODRFSMR APNI 14253 S. AIRPORT WAY crrvMANTECAT CA 95336 PARCEL StEE/APN1198-03-04 OWNER'S NAME r_ TIF rR(LT KC(1NR ADDRESS 9nR RTTRV (IT _RTPPIN _ CA PIOME0909_471 —1 787 CONTRACTOR VRW DRTTTTN(] TNC_ ADDRROP0 RnX 51 uc.770g04 FHONE''074747R15 AVB CONTRACTOR ,SN,,,SRIO VISTA, CA OLiS7) PHONES TYPE OF WEUNUMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MOmYOPNG WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-0ONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ./ ❑Naw❑R«W H.P. DEPTH PUMP SET----FT. FIRST WATER LEVEL O (TYPE OF RUMP) ❑ WELL ❑ OEORIY6ICK WELL I Aq BOR BORING 4 B ❑DESTRucnoN: CLOSE BORING WITH NEAT CEMENT GROUT A T .R SAMPLTNG INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ DOMESTICI INVATE ❑GRAVEL PACKIME TYPE OF CASiNGMTEEL/VNC CIA.OF WELL CASINO 0 ❑ RUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ mF1GATICNIM ❑OTHER GROUT SEAL INSTALLED BY OROUT BMW NAME E ❑ momTOMNO SPOUT SEAL PIMPED: ❑Y•• ❑Ne CONCRETE MCESTAL BY DRILLER:❑Y« ❑Ne S APPROX.DEPTH LOCKING CHESTER BOXISTOVE RPE 5 PROPOSED CONSTRUCTIONRXSLUNO NUMB: MUD P.OTASY AIR ROTARY AUGER CABLE OTHER GROPED E I HE9EBY CERTIFY THAT I HAW PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE Ni ACCORDANCE WITH SAH JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO REGULATIONS OF THE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTNIES THE FOLLOWING:*1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TMS PERMIT IS ISSUED,1 SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALWOPSA.' CONTRACTOR'S HIRNO OR SUS{ONTRACTING SKINATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT m THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT Ie ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORASAN'S COMPENSATION LAWS OF CALIFORNIA.- THE!AMT MVSipM HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS`INS AT 11881 Aa- 211. COMPLETE DMVAN I AT LOWER AREA PROVIDED. ` c qwn X •Ilf -�1L`1''//''EE�2 �lyr—_ 1\V On. 4 1 d PLOT MN 0.le SeWI Ba•b Ie 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PHOPLRTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 1. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPARSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY fT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DPEVEWAYS,AND WALKS. ON THE PROPRTY OR ADJOINING PROPERTY. I BMARTMENT USE ONLY Ik APPxaHlen A««Lad by 01"'A Ms«Ibn BY BY D•u O«Vmlbn Irwp«Ibn By S D•re 06L� ACCOUNTINO ONLY: AIDS FACT PF CODES FEE INFO AMOUNT REMITTED CHECKSMASH RECEIVED BY DATE PERHIT/SEANCE REQUEST NUMBER INVOICE Z Pub Health Saw.-Enviro.173(1/97)