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UAPPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES' �V ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 12091469-3420 NOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED i [Complaw In TTklI 010) AFYLICATION 19 RIERE BY MADE TO T11E SAN JOAOLIIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOrx DESCRIRED.TATS ArrLICATION IS MADE IN COMr11ANCE WrTll BAN JOAOUM COUNTY DEVELOFI•+IHIT ET TLE,CHAPTER 9-1115.3 AND 114E STANDARDS OF SAN JOAQUIN COUNTY RIBL/C IIIEALT14 SERVICES,ENVIRONMENTAL HEALTH DIVISION.JOB ADDRESS/OR APNI 3197 r OQrC fl I0r/�� /µ PITT J d C I'l U 1107 rAnCEL SIZEIAPHI u ` '] OWNER'S NAME_Vail If C f IJ. /' -R ADORESS O 690117 PHONE 1 (6J � /j lL-r C ON1 RAClOR v 4 !/l ^lf0 l�"Vl r/1114[n fA( F1 ADOnES11 Vd I lel P11 4 L J ""1f+ UPI. 9 422 7 r510NE I 4''5]6-VL ( {/ SUBCONTRACTOR V0"1C V Ca Vt fr M�� E AbORESB G. IYIQrAA f ucr �O m HEf /� TYPED WELummir; ❑ NEW WELL ❑ mrLACEMENT ITLI ❑ Mo NITbRING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROPS CONNECT RErAin ❑ VAPOR EXTRACTION WELL IF J ❑ N—CI Re.p.1t H.P. OEr7H PUMP SET FT. FIRST WATER LEVEL O H YrE OF r•VMPI ❑ OUT-O F.FEAVICE YJEtL ❑ OEO PI IYSICAL N'E LL/ is 601E BORING &71d I I ❑DESTRUCTION: I INTENDED USE TYPE OF WELL CO NS TMVC T10i-1 P—EC IHC A110NS (I A } 11INEwril"At ❑orw BOTTOM �/DIA.OF WELL EXCAVAI ION / OIA.OF CONDUCTOR CASINQ 4 D ❑ D0ME9T1CJMtVA7E �❑T GRAVEL PACK161ZE TYT'£OF CAFINGIfiT EF LR•VC `I / 1 DIA.OE WELL CASING [� D 11rUBLICIMUNIerrAt 60 DRIVEN DEPTH OF GROUT SEAL T, al Vc: ST4CIrICATION fy R ❑ InRIGA710N1A0 ❑OTHER GROUT SEAL INSTALLED BY IIM«•-e V I IC GROAT BRAND NAME RSII{T E ❑ MONITORING GnOUT SEAL r11MILO; ©Y.. R N. p/ CONCRETE PEDESTAL BY DRILLER;yLX Y.. Ne 5 APPROX.DTYTH Z 0 LOCKING CHESTER B13XOPIOVE FIK M+/A � S PROPOSED Wl CONS TAUCTIODRILUNO METHOD: MUD ROTARY AIR ROTARY AVOER CABLE 'OTHER ��O Y7C I HE4ERY CEnuFY INAT I HAVE PREPARED THIS ArT'LICATION AHD THAT THE WORK.WILL BE DOHS IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORb:NANCES.STAIF LAWS.AND RULES ANO nEGULATION9 OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT-R SIGNATURE CEMIRIES 114E FOLLOWiN13:•r CERTIFY THAT IN THE FERrORMANCE OF TIIE WORK FOR WHICH THIS PERMIT III ISSUED,I SHALL NOT EMPLOY MRSONB SUBJECT 10 WORKMAN'S COMrENRATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR FUS.CONTRACTING SIGNATURE CERTIFIES T11E ROLLOWING: •I CERTIFY THAT IN 114E T•ERl OnMANCE OF TITS WOrK ROM 1,M41CH T1111;rERMrT IS ISSUED,I EI{ALL EMPLOY FERSON9 SUBJECT TO WORKMAN'S COMFIDOARON LAWS OF CALIFORNIA.- 114/E y&PP��1 CART MUST CALL 2R HO N ADVANCE FOR ALL REQUIRED ILMI MONS AT 110014112y1211. COMPLETE OMAWINO AT LOWER AREA rROVIOED. Src, d i! '!/ f� J Tlli, L h r r d h k e C ,.. Rol PIAN IQ—I.SO.:r1 r-1- R, 1. NAMTA Or STREET 9 OR ROADS NEAREST 70 OR FIOLINDINCI THE r ROMIltY. 4, LOCATION Or IIOUAE RI WACE DISPOSAL SYSTEM On rYIOPOSED 2. OUTLINE Or III(mVptMY,GIVINO OIMENSIO148 AHO NORTH DIRECTION. EXrANS10N OF SEWAGE DISrOSAL SYSTEMS. 3. OIIAr NFRONFO OUTLINES AND LOCATION Or ALL EXIB'TING AND FTROMrEO B. LOCATION Or WTLL9 WrFHIN RADIUS OF ONE HUNDRED rIFTY FT. SInVCTVnEB,INCLUOINO COVERED AREAS SUCH AS FATIOS,DRIVEWAYS,ANO WALY•S. •. .r•.«�.��-_r ON THE FnOMMYOR ADJOINING rTIOMMY. PC RED 1918 �i Advanced Geo Environmental I r . I Of Northern California ) (209)956-0264 1803 W. MARCH LANE SUITE A(209)956-02¢4 11.35/1210 I STOCKTON,CA 95207.6414 J! '� -IL�`i.. . . . _ <�`! � /1 9 1997 1139 S 1� PAY €IvVlf�C1;4FJLP�TR! `1::.r :.''I rI',. 89 . 00 s I o'11-I o, San Joaquin Count PHS-EHE] RDER j DOLLARS �'o.... En Bank of America (2091546.0230 March Lane Branch 131139 , 1546 51.Marks Plaza 51OCMon.CA 95207 / PORPermit for Job 97-0301 1t'00 19 1811' 1: 1 2 1000 3 581: 1 1 39 7FFl 1 5 5Os'In I .... ...... . - v _ . •s. ' . •.i