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oO6 G � v APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, /'.i- ENVIRONMENTAL HEALTH DIVISION 9 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468420 NON-REFUNDABLE PERMIT "FIBER 1 YEAR FROM DATE ISSUED MempAu he TrlpNuEBI APPLICATION IB HERE BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOADIMN COUNTY DEVELOPMENT TITLE.CHAPTER 0-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH BERVICES.ENVIRONMENTAL HEALTH pppRRRgMQQL�N, (J(7 JOB ADDIESOMM APNI 8144 LATHROP RD, Cm NiANTECA PARCEL BIZVAMI Ap O 'er+ OWNEM'B NAME E D & C 0 N N I E CHIC 0 I' I E ADDRESS C/o Mina udo .Calst.22757 Tinnin Rd. � 823-0829 cow,ACTGMHENNINGS BROS. DRILLING CO. , INC. ADm,, 3525 Pelandale flrxles uc, 290813 PHONE, 545-1185 BUB COMPACTOR �Ipq1 PADDRESS g53Slo- 1'7 Y(LIC. PHONE, TYPE OF WELPU LIMP: VV NFW WELL ❑ REACEMENT WELL ❑ MOMTORINO WELL, ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CrOBFCONNECT REPAIR ❑ VAPOR EXTRACTION WELL, '- ❑NwclH eIr H.P. DEPTH PIMP SH—FT. FIRST WATER LEVEL O PYPE OF NM% ❑ OUT-0E-SERVICE WEIL ❑ GEDRIYSICAL WELL I ❑ BOIL BORING B ❑DESTRUCTION: INTENDED USE TYPEOF WELL CONSTRUCTION SPECIFICATIONS A M0 N11 INDUSTRIAL 1p1-I OPEN BOTTOM DIA.OF WELL EXCAVATION 12E111 DIA.OF CONDUCTOR CASINO O IM DOMESTIC P ATE P,J GRAVEL PACK/SIZE TYPE OF CASINGMTEEUPVC PVL. DIA.OF WELL CASINO 611 D ❑ MRMMUWWAL ❑DRIVEN DEPTH OF GROUT SEAL 100 , SPECNICATMN R F N T O N I T E M ❑ IRRIOATIONIAO ❑OTHER GROUT SEAL INSTALLEDBYH E N N I N G S GROUT BRAND NAME E ❑ MOMTONNO GROUT SEAL PIMPED: M Ym 11 N- CONCRETE PEDESTAL BY DRILLER:❑ lo Ym OPNe 5 Ap OX,DEPTH LOCKING CHESTER BOXIVOW RPE M IADPOBM CONSTNICITONn R LUNO METHOD: MUD ROTARY X X AIR ROTARY AUGER CABLE OTHER I HEREBY CERT Y T14AT I HAVE FTEPARED THIS APPLICATION AND THAT THE WOW WALL BE DONE N ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND SI OtMTIONS OF THE SAN"AMN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWNO:'I CERTIFY THAT W THE PERFORMANCE OF THE WOM FOR WHICH 1141f PERMIT 18 ISSUED,1 SNALL NOT EMPLOY PERSONS SUBJECT TO WDIUUEAN•S COMPENSATION LAWS OF CALIFORMA.' CONTRACTOR'9 HIRING OR SUB-0ONTRACTNG SIONATUPE CERTIFIES THE FOLLOWIFO: -I CERTIFY THAT N THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORIOMAN-B COMPdSANON LAWS OF cmTrORMI A.A." THE APPLICANT MUST CALL 2HO IN AMAI*C EFOR ALL REOURSD INSMMMS Ar:=22.♦S 22. COMPLETE DRAWING AT LOWER AREA R VIDEO. B,N-MX-rI Omml RIL 1(}\J IXnI �//T ,LJ,`K'�1111M1'^ D.H OCT. 7 , 1998 ROT RAN plrwv to BaNN BaN. 'to 1. NAMES OF SIKH$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR POOMSED 2. OUTLINE OF THE%OpERTY,NVNM DIMENSIONS ANO NORTH DIPECIMH� EXP NEON OF SEWAGE DISPOSAL BYSTEM8. J. DIMENSIONED OUTLINES,AND LOCATION OF ALL EXISTBO ANO PIROFiOSEb S LO Al N OF WFLLB WT11N MODS OF ONE HUNDOEO FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAUX8. ON HE MKITTY OR AOJGINNG PROPERTY. r Q �l. 1 o r s F � Inl MAW: va D 1a1,(�,�1 m EA 'p pr i OCTppE91998 HEAl- HjgCg4tC HEALTHmiI. !kN'JIFjGNtdEMr,. F_R-'fM 111Vf.. r i 7 7. DUARTME T USE ONLY AmMElim MaFPt.d By Grein Bnpmllm BT D.u�ja_7"A-$�'.nP Iropmtlsn BY ON. Omtrwtbn AL2.' ONe 0 itv(. C 14 nv 17T-22 S'/2?-to -245 r-4 s1 wc, 2o` sae TL ST Cemmerwc SE1v 1-f N o IA rex-ago(' 'L-! © )+ u L &Rolti 2L. ACCOUNTING ONLY: AID, FACI ✓`� - PE CODES FEE INFO AMOUNT REMITTED CHECK, ASH RECOVEG BY DATE PERMIT/SEANCE REQUEST NUMBER INVOICE R 5070 /o 01-7 e„1, un+Ph Cnn. .Fn.•bn 1T7 (IMT