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PAYMENT APPLIC1.TSON FOR WELLIPUMP PERMIT `" RECE1VEt7 SAN JOAQUIF�UNTY PUBLIC HEALTH SERVICES �' `�u ENVIR• ENTAL HEALTH DIVISION 5-7r4�7&^J NOV 2000 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 MOR-REFUNDABLE PERM/ EXPIRES 1 YEAR FROM DATE ISSUED � SAN Ic ME��GAUNT ICampleh in TrlplleEtal ` API'LICh PUOLIC HEALT�HN��Sp�E�TTRHIV{IpIVSSION i {��AIREIE'7G'THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WDFK DESCRIBED.71119 APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAGIAMUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS of SAN JOAWiN COUNTY{UREIC HEALTH SERVIICCES,ENVIRONMENTAL HEALTH DIVISION. ]Q JOB ADDIIESApR RPM/ ,// c CrTY •�"'r^fT7E-�Q/ PARCEL 872FJAFNF 0719`6 NAMEL /3 8-7�/�J AODRESR PHONE F CONE/ Fir— �p/L` AGGRESS I'2 S� //N-L "T I nun CONTRACTOR — L ADOREaS — /L/`�j/LT1-/.� RIONEI TYPE OF-„_WE 1LLRIM LJ HEW WELL Q REPLACEMENT WELL ❑ MONRORINO WELL � Q OTHER Q INBTALLATfON WELL SYSTEM REPAIR L � e CPXISS-CONNECT REPAIR /11 I--�e-p>❑VAPOR EXTRACTION WELL! J Q N—El Repels H.P. DEPTH PIMP SET (TYPE OF PUMP/ FIRST WATER LEVEL- 13 , Q OUT-OF-SERVICE WELL 13 GEOPHYSICAL WELL I *M.R.BORING e ❑DESTRUCTION• INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION! I Q INDUSTRIAL 13 OPEN BOTTOM A L--E DIA.DF WELL EXCAVATION (fl— 4 OfA.OF CONDUCTOR CASINO_-._ L DOMESTICIMVATE ❑GRAVEL FACKISIIE TYPE OF CAS D NNOISTEE GIA.OF WELL CASING p ❑RIHIJC/MUNONAE ❑DRIVEN DEPTH OF GROUT"At SPECIFICATION R ❑IRfUOATOONIAO Q OTHER CROIlf REAL INSTALLED BY GROUT B1ylND NAME E ❑MOMITOMNO i OROUI SEAL PVMPEO;[I Y. [IN. coxcIIETE PER>fsTALer DwuER:Ov.. C7Ne s APPROX.DrPTF W - LOCKINOCHESTER BOXlGTOVE RPE IE— S PROPOSE)CONSTRUCTIONrOMUNG METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER - I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN MAMA”COUNTY ORDINANCES,STATE LAWS,AND WI EB AND I REOUTATIONB OF THE SAM JOAOUIN COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTUIES THE FOLLOLWNGI•1 CERTIFY THAT IN TILE PERrORMANCE OP THE WORK FOR WHICH THIS PERMIT M IBSUEO,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OT CAIFORMA.•CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES h THE FOLLOWING: '1 CERTIFY THAT IN O CE OF THE WORK FOR WHICH THOS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORmIAAN'S COMPENSATION LAWS OF I CALIFORNIA.' THE CANT MVS A 4 1M ADVANCE FOR ALL REOLIIRLO INSPECTIONS AT IMS{480.9429.COMPLETE DRAIAINS AT LOWER AREA A10VIO '4 619-4 X TRH. ! /I C) r y S/ON�L— D.e. r` ' c�cS . PLOT PLAN NN—I.Sedd Si.Ie •t. - P,NAMES OF STREETS OR ROADS AREST TO OR SOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR POPOSCD T.OLFLWE OF THE PTOrERTY,)MNG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, - I.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND POOPORED - S,LOCATION OF WELLS WITHIN RIU ADS OF ONE HUNDRED FIFTY rT. B TRUCTURER,INCLUDING COVERED AKE"SVC"AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTYOR ADJOINING PROPERTY. 61 i ...... ... .. .... I ;....- .. ..,,. { loo P. •2. . .... f t :.. _ '.... �' :..... .. . ..... . . . .. DEPARTMENT USE ONLY Apptleellan Ae..ptad Bx Det �� / '^� •' Mr�>�49 OreuR In7pe.Ibn BY bele rb p,,1n.P de BY G.J. S1S oe.tr�,eneo In.Peelb. 9 p.R. I z I l/2'zaeo JO rs�RaXA! �03AoT ACCOUNTING ONLY: AID! FAC! 5_19A1,!D -2fl9alrlC (�•.rs SuR •� PaT.rIEl7P - PE CODE* FEE INPO AMOUNT REMITTED C"ECK! SH RECEIVED UY GATE P9WRTIBERVICE REOVEsr NUMSDI INVOICE Pub.Heahh Sery.•EIN{IO.173(1/97) - - I