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APPLICATION FOR WE Ll,/P IMP PERMIT ' SAN JOA COUNTY PI�BLIG DWSERVICES ENVIRONMENTAL HEALTH DlNISPON�,?`:i' 304 EAST WEBER AVENUE,STOCKTON,'CA 85202 (209)468-3420 NOR•REFUNDABLE PERMIT EXPIRES .YEAR FROM DATE ISSUER MampNtB Ii)TTipIk4tB) AM`LICATION IB HERE BY MADE TO THE SAN JOADUIN COUNTY FOR A PCOM1T TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.TOGS IAFPLICATION 18 MADE IN COMPLIANCE WITII SAN JOAOUIN COUNTY bEVELOPMEENT TITLE,CNAPFER B-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTII SERVICES,ENVIRONMENTAL HEALTH DMIllO�N.A JOS AMMESMOR APN# `Y E �/ CITY DJ PARCEL 811E/APN/ V A C OWNER'SNAME VI I ,A, 0V S�m •'.'- 11 /ADDRESS y PHONE# - �• - CONTRACTOR " 1 IL G- s 4 ADDREOG O UC,F 7 7 3 1 E PHONE I y_S/7 L5- SUBCONTRACTOR o VpS ADDRESS A` ()CF FIeGNE# i I TYPE OF WELL"mp:'KNEW WELL ❑ REPLACEMENT WELL ❑ MDNrToFt m WELL# ❑ OTHER ❑ INSTALLATION ❑WELL BYSTEM REPAIR ❑ CROSB-CONNECT REPAIR ❑ VAPOR EXTRACTK7N WELL# New❑Rep1Ar H.P. bEPTI1 PUMP BET FT. FIRST WATER LEVEL 6�- RYPE OF PUMPF (+ ❑ OUT-OF•BERVICE WELL ❑ GEOPHYSICAL WELL I ❑ Solt,BORING p r.{�I ❑DESTRUCTION; P-�y-�� INTENDED USE TYPE OF W CONSTRUCTION SPECIFICATIONS A �I �❑(INDUSTRIAL 1c❑OPEN BOTTOM DIA.OF WELL EXCAVATION CIA.OF CONDUCTOR CASING p A DOMESTIC/MIIVATf +1_1GRAVEL PACK/8@E TYPE OF CABINOISTEEIIPVrCt C' -+LI%3 OAA.OF WELL CASING +p � Im ❑ PISUCIMUNtCB'AL ❑DRIVEN DEPTII OF GROUT REAL `'0 Q Y_ BFECIFICATIOH R J ❑ IRRIOATIONtAG ❑OTHER GROUT SEAL TNSTALI.FO SY_�J f��NLI*+C.1 OROIR BRAND}TAME C- VA E yl ❑ MONITORING GROUT SEAL PUMPED. Yde ❑No CONCRETE PEDESTAL BY DRRLEij>�Yr ❑Ne S APPROX.DEPTH D LOCKINO CHESTER BOXISTOVE PPE S PROPOSED CON$TRUCTION(MI.IIPIG METHOD: MUD ROTARY--�AIR ROTARY AUGER CABLE OTHER „_„� ~—• I 11MAY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES ANO? REGULATIONS OF TIIE BAN JOAGUIN COUNTY, HOME OWNER OR LICENSED AOENT'B SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF TIRE WORK FOR WHICN TATS MRMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUD-CONTRACTING SIGNATURE CERTUIES THE FOLLOWING: 'I CERTIFY THAT IN TILE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 18BUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIWAN'$COMPIOMATIoN LAWS OF CALIPORNIA�THE A(P//P� eANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGt11REb INBFECTTONB AT I"01 4q,7123. COMPETE DRAWING AT LOWER AREA PROVIDED. SI$nea XA&' A11.� -- _.. .11116 t.v K Dole i PLOT PLAN Meow to 866161 Bede '!e I• NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TIIE PROPERTY• 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM RR pROPOSEO t. OUTLINE OP 114F PROPERTY,OWING DIMENBIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYBTEMB, I. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED � 8. LOCATION OF WELLS WITHIN RADIUB OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINMO PRDKn y, ,. .. :.....:: 3...::: Y � 1998 ... .. .. ::::. ....... AN 0 SIN a). ao LIG HEALTH SERVICES ENVIRONMEMAL fiEALTH DIVISION 1 DEPARTMENT UBE ONLY • �"�'AnlillewlRrn-Aa6heter!By�v�.'r�r.._-.::_-r�:,,�e..�--.� A- - -- rv�'- �-—=�"��-.� - �-- -''u '�--`-..� Q _ - _,__ �_-..., t,.6ul Trxneallen By _ l s'/F1'1fmP IMPeetlen BY j Dote _�.y D-Irmllen Inepectlon BY CemmerMe• ' ACCOUNTING GREW AIDN - FAC# - - PE CODE$ FEE INFO AMOUNT REMITTED CISEc 1CA$H RECEIVED BY DATE PERMITIBERVICE REGUE$T NUMBER INVOICE ! (o0 Pub.Health Serv.-Errviro,173(1/97)