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""PLICATION FOR WELLIPUMP PERMIT SAN t AOUIN COUNTY PUBLIC HEALTH SERV ?S ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDAKE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompbt1 In Trlpikst■) APPMATIOH I5 HER BY MADE TO THE SAN JOAOM COUNTY FOR A P U ALIT TO CONSTRUCT ANDATR INSTALL THE WORK DESCRIBED.TFRS APPLICATION IE MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVEL 7 AP[ 1 6.3 AND TFIE SrANDAROS OF BAN JOAOUH COUNTY PRRJC HEALTH SEKVICEe,EtrWFPDNMTNTAL HEALTH DIVISION. O-25M 1 TE.2-, JDenaoHEssroRAVH�p'ay�1��rQ,�7 ]�iT��s f�IEteUCn +1J$+ y CITYI/�s�1`/�]1CyV y J f PARcE/tmzEJAPHr 73C1Clg5 �J OWNER'SNAME F -iph-2. LI.5-A, —oyi t!_,k rl) ADDRESS P, soo 57 Pr,Iy!?�r(J{�J/�I'i PA rFLgHE/ :(-��'y��pg�/� CONTRACTOR C"P !] ��I��I�CI!�1 rLTi�I� G ADDIEi. f.Xl HOW RTI. MCOPRRACTOR ADDRESS LIC/ PHONE/ TYPE OF WELLrIJMP: ❑NEW WET). ❑REPLACEMENT WELL ❑MONITOTSFIO WELL• ❑07M ❑INSTALLATION ❑WELL SYSTEM REPARI ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTIGH WELL F J ❑N—1:1 n-.4 H.P, DEPTH PUMP SEf R. FIRST WATER LEVEL D rtYPE DF PUMPI ❑OUTAFSUMC�E�WELL L ❑..EyGEOPHYSICAL F1 TWELLI ❑DEvrnUcTKHI: r'H s PLL IN TFJ.DED VSE 7 E OF Wfll CONSTRUCTION SPMHCAt1ON4/1 ( y A F❑T INDUSTRIAL ❑OPENBOTTOM DIA.OF WELL EXCAVATION -_7,r GIA.OFCONOUCTORCASI"O N A- D lL-,OOMESTICRRIVATE I1:1 GRAVEL PACKMZE TYPE OF CASINOISTEELMVC 7 /; DIA.OF WFLL CASINO 11 L PPSLIC/MUNICIPAt 1-J DRIVE" 1� � ,�� DEPTH OF GROUT SEAL it WECIMATION A ❑1RISGATIONIA6 OTHER CCI rL GROUT SEAL WRTALLED BY MA rI 1( GROUT RRANO NAME MONROF9IJ0 / GROUT SEAL PIMPED:P4 Y. ❑No COHCF E PEDESTAL SY DRUER❑Yw i7lla APPROX.Do" 10"12 LOCKING CHEATER Soxmow PPE N/,14 /Vim/ J S PROPOSED CONSTKUCTIONIDISLUND METHOD:MUD ROTARY AIR FIDTARY AUGER CABLE OTHER O ivh<fEL6A veliDVIlC CThtmer I REVERY CERTIFY THAT 1 HAVE PREPAPEO THIS AFRJCAT10N AND THAT THE WORIL NALL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGU.ATIONR OF THE RAH JOAOUIH COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE POLLOWINO;'I CERTIFY THAT IN THE PEWORMANCE OF THE WORK FOR WHICH THIS PERMIT IR ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATON LAWS OF CALIFORNIA.'CONTRACTOR'S NRSHO OR SUB.CGNTRACTWO SIGHATURE CERTIFIES THE FOLLOWMG: •1 CERTIFY THAT IN THE PEWORMANCE OF THE WOW FOR WHICH THIS PERMR IR ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORVMAR'S COMPENSATION LAWS OF CALR-ORMA.• NE llt•R/CANT-..T CALL N L UR►IR A°°��'' 1 FOR ALL hEOURm IRePECTOlIe AT.—,4S1-fa=S,COMPETE ORAtWIG AT LOWER AREA P+OVKOED. e w.+x_�trFTLG� 7• ��y Lc;r}Lt� trR. Cil v, Cl „ D.I.. POT PIAN W...•!•S..41 S..I. M P.NAMES OF STREETS OR ROADS NEAJEST TO OR SOUNDING THE PROPERTY. A.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,CIPANO OTF.ITNSIONS AND FORTH DIRECTION. ExpANSiON OF SEWAGE OIspooAL SYSTEMS. 3.DIMENWONEO OUTLMF.S AND LOCATION OF ALL EX19TFNO ANb VMPOCED 1.LOCATION OF WR"WITHIN RAbrUS OF ONE HUNDRED FIF7Y rT. STRUCTURES.INCLUOING COVERED ARF LB SUCH AS PATOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. . ...__ ---. .................. . DEPARTMENT USE ONLY APPS.nbR Aso.Pld By E 1 'r i [NM I.wPxllen BT OH• f+1mp M.P..tlrtn By G.T. D«Inrlbn tiv, O BT .1• AG[vUHTTMO ONLY: AIDI FACT e�Yl�l PE CODES PEt INFO AMOUNT REMITEDCPt€CyJIEAIN RECELVED RY DANE PHSHITfAERVtCE REQUEST NU.MG! �fNVOtCE Pub,HeM Sen,-Err*o.173(1/97)