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as-� 7s- <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS/IHS BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONBTRUCT AND/OR INSTALL THE WORK OEBCRMED.TIOB APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> "AW COUNrY DEVELOPMENT TRI),CHAPTER 9-1115.3 AND THE BTANOAROS OF BAN JOAQUIN COUNTY KMX HEALTH BEMACEB,ENVNIONMENTAL HEALTH oMBION. <br /> Joe AODIIE RAPIS 2514 East Juliet Road Cm, Stockton PARCEL MZF/APN/ <br /> OWNER'S NAME <br /> Rete en Costillo ADORES/ Same PHONE 465-8004 <br /> coNTRADTOR Clark Well , Inc. ADORl--E Charter teen 371560PRONEE 462-7676 <br /> am CONTRACTOR ADDRESS MIT PHONE# <br /> TYPE OF WELUPUMP: ❑ NEW WELLTTT��}❑yy, REPLACEMENT WELL 11 MONITORING WELL I ❑ OTHER <br /> S� ❑NINSTALLATION y WELL BrEM REPAIR 11 CROSB GNNECT REPAIR El EXTRACTION WELL I J <br /> ❑N.0 nse k N.P. I• I DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ITYPE OF PIMPI <br /> ❑ OUT-OF SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYFE DF WELL CONSTRUCTION SPECIFICATIONS A <br /> 11 INDUSTRIAL C1 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ OOMESTrN W VATS ❑GRAVEL PACK/SITE TYPE OF CASINO/STEEUPVC DIA.OF WELL CASINO O <br /> ❑ RIBIIC/MUNIcIPAI ❑DRIVEN DEPTH Of SPOUT SEAL "CIFICATION R <br /> ❑ IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY OROUT BRAND NAME E <br /> ❑ MONITORING GROUT 6EAL PIMPED: ❑Yr [IN. CONCRETE PEDESTAL BY DPLLEe:❑Y— [IN. 9 <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PPES <br /> PROPOSED CONSTRVCTION/DISLLINO MUMD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTI HAT I HAVE PAE0 IARM THIS APPLICATION AND THAT THE WOW WILL BE DONE M ACCORDANCE WITH SAN"AMIN COUNTY ORDINANCES,STATE"We.AND RULES AND <br /> REGULATIONS O E BAN JOA OV MY. OWNER I-ENBED AGENT'S SIONATURE CERTIMB THE FOLLOWING;'I CERTIFY THAT IN THE PEKOPALANCE Of THE WORK FOR WHICH <br /> THIS PERMIT IB I D,I BNALL T OY R BUBJE TO WORKMAN'S COMMSANON LAWS OF CALRORIBA.- COMM TOR'/HIRING OR W"ONTRACTINO BIONATUBE CERTIFIES t <br /> THE FOLLO 1 CERTIFY THA IE E OF HE WORK FOR NMION THIS PERMIT IB ISSUED,I BNALL EMPLOY PERSONS BVBJECT TO WMKMAN'S COMPENSATION LAWS OF 1 <br /> CALIFORNIA. T U S 1 ADV E FOR ALL REQUIRED IN6F 1110 1@ AT(201114b.Ss2a. COMPETE DRAWING AT LOWER AREA PROVIDED. <br /> Ker..eK Till. Sec—Tres D,,, 21 May 98 I <br /> PLO MN ID, .Is Sco.I Be.l. 'Is <br /> 1. NAMES OF sT1EUs OR RD NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. ONIUM OF THE PNOPERTY, mMENSRONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBMIAL SYSTEMS. I <br /> 3. DIMENSIONED OUTLIES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADWS OF ONE HUNDRED Flf PT. <br /> STRUCTURES,INCLUDING COVERED AREAS OWN AB PATIOS,DRIVEWAYR,AND WAIXB. ON THE PROPERTY on ADJOINMG PROPERTY. <br /> 1s1 <br /> "P� r= 4YMENT <br /> MAY 2 21998 <br /> SAN JOAQUlN <br /> OpII <br /> ' - <br /> PO UNtY <br /> tE Hrrµ,TH SDNVICES <br /> I( VIRONMENTAL HEALTH DIVISION <br /> �� OCPMGAE T Usk ONLY <br /> AiAes..1.J By Y VVVYT/`� -ail D. <br /> n' <br /> Gre,n HrwPembn Sy Dm P.nP Imvdenn By , J I Oe. <br /> Oa.rncnen I,wnslbn Pv D.R. <br /> comm>nr <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE CODES TIO INFO AMOUNT"EMITTED HILCKI SN RECEIVED■Y DATE PEIIMITIe ETIVICE REQUEST NW&M INVOICE <br /> 8(va Ld 5/aal9SCr <br /> Pub Health Sew.-Env,ro. 173(1/97) <br />