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APPLICATION FOR WELUPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 d NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cemplete In Triplicate) AhR`LICATION 1911ERE BV MADE TO 111E SAN JOAQUIN COUNTY FOR A PERMIT TO CONBTRl1CT AND/OR INSTALL THE WORT(DESCRIBED.TARS APRICATON 18 MADE IN COMPLIANCE MITI SAI) JOAQUIN COUNTY DEVELOPMENT TITLE.CNA,PTTEER 9-1115.3 AND TIIE STANDARDS OF RAN JOAQUIN COUNTY PUBLIC IIEALTII SERVICES.ENVIRONMENTAL IIEALTII bMS10N, ./OR ADOnESSIOR APNI I C- \ C1 v `-J-CA— '/ •� CITY `1V P / 1 \ J� (J L� PAIICEL R12ElAPIJI- qU Q L1Z1J owurn'9 NAME � P) \ n ALONE CONTRACTOR_/y CS7�-- �w��C-m-" Q l ?y,} - �� ADORE 69 CL ,T�L «111_IC101--7/`t-� PYRONE.I SU"CONTRACTOR ADORERS (\'-'�r� C/ P/IONF/ TYPE OF WELLJPUMP• ❑ NEW WELL ❑ nF AGEMENT WELL ❑ MONNOAINO WELL I ❑ OTIIER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR089-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J Nww❑itenwlr fI YP`E OF P'VMPI II.P. DEPT11 PUMP SFT FT, rIRRT WATER LEVEL / ❑ OUT-0E-SEnVICf WELL ElOEOAIV SICAL WELL I WV ROTI BORING raS R ❑DESiRVCT10 N: INTENDED U{E TYPE OF WM CONSTRVCTION{PECIFICATIONa ❑ INDUST RIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.Or CONDUC Ton CASINO A ❑ DOME97ICIR9OVATF ❑ORAVTL PACK/SIZE TYPE.OF CA9INO/BTEEL/1'V DIA.OF WELL CASINO O _ D PURLICIMVNICIPAL 13 DRIVEN DEPTII OF GROUT BEAL SPECIFICATION R ❑ InruGA710NIAG ❑OTNER OROVT BEAL INSTALLED BY GROUT BRAND NAME F ❑ MONITOrVNO GROUT BEAL PUMPED: ❑Vr ❑Ne CONCRETE PEDESTAL BV DRILLER:❑ [:IN. Ne S APPROX.DEPT" LOCKING C1IE6TER BOX/STOVE r'IPE S PROPOSED CONSTRUCTION/DP9WNG MET"OO: MUD ROTARY Ain ROTARY AUGER CABLE OTHER I IIF9FRY CFnTIrV TIIAT I IIAVE PREPARED T"19 AFTLICATON AND THAT TIIE WOPK WILL RE 170NE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OIOINANCE9,STATE LAWS.AND nULF9 AND RFOUt ATIONS OF TIIE BAN JOAOVM COUNTY. IIOME OWNER OR 110EN8E0 AOCW'9 SIGNATURE CfRT1RE9 TNF FOLLOWMO:'1 CERTIFY THAT IN THE PERFORMANCE OFTIIE WORK Fon 1MIIC11 THIS PERMIT 1919SVF0,1 SUAt L NOT EMPLOY PER80NS RLIBJECT TO WORKMAN'S COMPSNSATTON LAWS OF CALIFORNIA.- CONTRACTOR'S HIlUNo OR 9UB.CONTRACTIN910NATURE CERTIr)E9 7 if rOILOWINO! '1 CERTIFY TIIAT M TIIE PERFORMANCE OF Tr1E WOPK FOR WHICH THIS PERMIT 19 19eUFM 1 RIIALL EMPLOY PfnSONR RUBJECT TO WORKMAN'S COMPENSATION LAWS Of CAI.KO TH[Ap%.=�NT MVS ALL ZI r10URS IN ADVANCE FOR ALL REOURIED INS►ECT/O(SATT f"01/gJ/tf. COMPLETE DRAWING AT LOWER AREA PROVIDED, (��r 91pnwA X cTitlw VL L��YI L �TL Dwtw_ I — /PJ PLOT PLAN 9),"to 9p0.1 Rewtw 'to 1. NAMES Or AIRE"8 OR VADS NEARERT TO OR BOVNOIRO THE PROPERTY. 1. LOCATION OF IOUBE SEWAGE VIRPO9AL 9YRTFM On MOPOBED 2, OUTLINE OF TIIE PROPERTY,GIVING OIMENO"S AND NORTH DIRECTION. EXPANRRON OF 9FWAGE 040MOAL 9Y9TEMS. J. DIMENRONED OVTLMER AND LOCAMN OF ALL FXIR'TMG AND PROPOSED a. LOCATION OF WF119 WNIIN RADR/9 OF ONE I/UNnmp rirTY FT. STRUCTURES.MCLVDINO COVERED AREAS BUCK AR PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. : C� :. ..:. .... :PAYMENT PECEIVE FEB' 12 1998 PUBLIC HE 4LTH LIIN 3rnvI E8 _ EN AL,HEALTHDIV VIRONMENT DF►MTMEHT VSE ONLY Apelf.01 AeewplwA BY / Dwtw -1n O,eu1 ImpentMn BY �Owtw An,p In.pwnUwn BY Owlw 01 hS ACCOUNTING ONLY: AID/ rACI if re/ W Pf CODES FEE INTO AMOUNT REMITTED CIIECKfMASII RECEIVED■Y DATE ►ERMIT/SEIIVI E EOVES NUM9[R INVOICE Puh Hnalth Serv.-EnvIrO. 173(1/97)