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APPLICATION FOR WELL/PUMP PERMIT SAN J'�.A.OUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 -3420 RON-REFUNDABLE PERMIT)EXPIRES I YEAR FROM DATE ISSUED FILE COPY 213 T6 FVfk j c (Complete In TriplkBtel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPIANCE WLTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111513 NO THE BT MOARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE880OR APNI Z 1 Y J L :) "e#_ CrIY A�T r a r Y PARCEL SIZE/APNI OWNER'I NAME Mary Correia ADOWS8 pHo I 8 1 4-5 8 6 3 CONTRACTOR FYPi rAg F1 PC tris TnC . ADDRSI P . O . Box 16 , BAn U® 45396&4oNE1835-2814 BVD CONTRACTOR ADDNE88 (JCI MORE TYPE OF WELLA`UMP: ❑ NEW WELL ❑ RENNACEMENT WELL ❑ MONNTTORIM WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM AFFAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J C I1 h ❑N.v.q Rw.l. H P. I OEM"PIMP SET- C,n ,FT. FIRST WATER LEVEL O (TYPE OF PUMP( ❑ OVT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING B ❑OEBTRtJCTION: INTENDED USE TYPE OF WELL CONSTRICTION SPECIFICATIONS A 13 INDUSTRIAL ❑OPEN BOTTOM CIA.OF WELL EXCAVATION GIA.OF CONDUCTORCASINO O ® DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOJBTEELJPVC GIA.OF WELL CASINO O ❑ MOM MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION S ❑ IMOATIONIAO ❑OTHER GROUT SEAL INSTALLED BY OPOUT BRAND NAME E ❑ MONITORING GFOUT SEAL PUMPED' ❑Vw [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑N. 5 APPROX.DEPTH 74 F LOCKING CHESTER BOX/STOVE PR 5 PROPOSED CONSTRUCTION/DNWNY METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HMNY CERTIFY THAT I HAVE PIEVARD THIS APPLICATION ANO THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR MENSM AGENT'S SIGNATURE CERTIFIES THE FOLLOWING''1 CERTIFY THAT IN THE PERORMMCE OF TILE WORK MR WHICH THIS PERMIT IB ISSUED,I SNALL NOT EMPLOY PERSONS SURJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOPIIIA.• CONTRACTOR'S HIRING OR 6USCONTRACTIM SIGNATURE CERTIFIEK I THE FOLLOWING' -1 CERTIFY THAT W TIE PERFORMANCE OF THE WONT FOR WHICH THIS KRAFT IB INSUED,I SHALL EMPLOY PERSONS BUBJECT TO W"WAN'S COMPENSATION LAW$Of �• CALIFORNIA.- THE AI C HT MUST CALL N IgIA4 IN ADVANCE FOR ALL REOIDISM 1141* CTTONB AT ILSBI.SSJSIS. COMPETE DRAWIM AT LOWER ARA PROVIDED. _ BIS.MX TR. President D.I. 4-29-99� PLOT FLAN R —1.Sa..l Rv.b •1e ( n 1. NAME OF STRETB OR ROADS NEAREST MOR BOUNDING THE PRDRRTY. 4. LOCATION OF HOUSE SEWAGE NGPOBAL SYSTEM OR IOONOSM Z. OUILINE OF THE PROPERTY.GIVBC DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE p8PO6A1 BYITEMB. T. DIMENSIONED OVILINFS AND LOCATION OF ALL EXISTING AHO PROPOSED S. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY R. BTAMTVREB.BNCLVDINO COVERED AREAS*MIT AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY On MJOINIM PIOPEJ Y. C� S CChh :MAY 4 19 MTMFNT UBE ONLY Yy Gr.u1 In.Pwtiv..Br O.0 P.nv mwwll.n ar - 'ON.��•`Z?— DsbuoB.n I,wn«IIa.er D.1. n•29-Q� <.mms.l.: s oT p'T/3rCy MK Moe ra11/ ACCOUNTING ONLY: AIDS FACT PE CODES FEE INFO MIOVNT REMITTED CHECK$ ASN MCRVED BY DATE PERM(TJSERVICE REQUEST MINIKES INVOICE ?i FSU DJO 9 019/3 / Pub HsB h Serv.-EnvirG. 173(1/97)