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APPLICATION FOR WELL 'PERMIT SAN JOAQUIN COUNTY PUBLIC I'TCALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ IC."kis In TIIPIkI°I) APPLICATION 1911ERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT to CONSTRUCT ANnUOR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPIANCF WIT It SAN JOAOUIN COUNTY DEVEI.OPM�I TITLE.�1�Efl 8-1115.3��Jp T1�STANDARDS OF BAN JOAQUIN COUNTY^B^CEAITII 6FRNCE9,ENVIRONMENTAL B z�,T�:IVIeION. JOB ADDRESS/OR AEN/ -Tc)l'1PQ L I S ` 'I -rl cc Y l R 1 OWNER'S NAME - Tr d lI I h Y_S ADDRESS`I�n L r I.J��I�r,to 11 , SG A JFOSG F n /]s CONTRACTOR fel CI I Y.� Clec .enc-. ADDRESS PO l3Dx III (3cEnt4 LICI L1539f, MIONEI Irl SVS COWRACTOR ADDRESS LK;I PHONE TYPE OF WELVPVMP: 11 � NFW WELL ❑REPLACEMENT WELL ElMO.RORINO WELL I ❑OTHER LJ INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS CONNECT REPAIR Cl VAPOR EXTRACTION WELL/ .1 L 11 Fl—❑ReP.lr H.P. DEPTH PIMP SET_FT. FIRST WATER LEVEL O n YEE OF PUMPI ❑OW-OF E.VICE WELL ❑GEOPHYSICAL WELL I ❑ NOR.BORING / �l ❑DESTRUCTION: INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATION&. A G �❑INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O LJ G0MFSTICfF"VATE ❑GRAVEL PACKMIZE TYPE OF CASINO/STEfVPVC DIA.OF WELL CASINO O� ❑ MIMIC/MUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL SPECIFICATION S (� ❑I.M.ATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F r� ❑MONHTORINO GROUT SEAL PIMPED:❑Yr ❑N. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑Ne 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE APE S PROPOSED CONSTRUCTIONIOPoLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HERESY CERTIFY THAT I HAVE PREPARED THIS AF"JCATION AND THAT THE W W WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY DMINANCES,STATE LAWS.AND RULES AND PEDULAT ION9 OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGFNT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE wow Tom WHHICIH THIS PERMIT 19 ISSUED,1 911AIL NOT EMPLOY PFRSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-COW MCT OR'S AIRING OR SUB COMPAC T IND SIGNATURE CERTHFHEB THE FOLIOWINO: '1 CERTIFY T/IAT IN TIIE PERFORMANCE OF THE WORK FOR MOICIH THIS PF.RMR IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAI IFORNIA.' T APPUCAN-TT MUIT CALL II IIOUITS IN ADVANCE FOR ALL REQUIRED INIPECTIONS AT 12OS11 4U CCOM�PLITI.O.M"III AT LOWER ARTA P[M DED. �j/� &.lewd X >J L^^"-' TIII. � _ D.I. / —r�6 —! / ROT PLAN 031—re Ik I.1 1. NAMES OF STI EEIS OR ROADS NEAREST TO On BOUNDING THE PROPERTY. S. LOCATION OF HOVBE SEWAGE DI9ROSAL SYSTEM On PMFOSFO 2. OLFILINE OF 1HE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYBTFMB. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WIHJ.8 WRMN RADIUS Of ONE HUNDRED FIFTY R. STRICTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY. - _ .. .. v - I D Vc r \f OCT ,7:1997 SAN JOAOUIN COUNT Y '. - - - PUBLIC HEI LTH SERVICES TO E'NVIRONMFNTAL HEALTH DIVISION DF►MTMENT VSE ONLY APPIic.Ilnn Ac. IM By Or.ul I—P.-I..BY P—P t-P-11—By 11.wtrrrll.n I-p-11—By 0.1. ce,nme,l.: [Jt��ycL_r�/311,u.Rt�PEN H-cJr 7�!'-OkNh f�P ACCO VNIHNO ONIy: ND/ FACT PE CODES FEE INiO AMOUNT REMITTED HECK ASN RECEIVED BY DATE PERMIT/SERVICE REOLIEBT NUMBER INVOICE 7 67 Pub.Health Serv.-Envlro.173(1/97)