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I APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCICTON, CA 952�r r-- - 7(209) 469--3420 Lj WON-REFUNDABLE PERMIT EXPIRES ] YEAR FROM DATE ISSUED ! ICBmpkte In TTIpRcal71 ' �F APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDA]R INSTALL THE WOW DESCRIBED.TMS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENTT1111,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# 2256.3 So . 7th St CITY Banta PARCEL SIZEIAPNf OWNER'S NAME Banta Inn ' Aoonese P . 0 . B x .34 Banta .a PHONE 4 3 5-- 1 3 1 1 ! CONTRACTOR Freitas E1"-ectric , Inc . A� S� . 0 . BX ' 16 Baa�n�Jta , 53962 FHDNef835-2814 on SUB CONTRACTOR ADDRESS` 3L/.. LICE PHONE N I TYPE OF WELLIPUMP: © NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER 5 ll h ❑ INSTALLATION 13WEELL////L;;;SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 J [ 11New❑Repair H.P. DEPTH PUMP SET 6 0 FT. FIRST WATER LEVEL 12 O {TYPE of PUMPI Rep 1 a c e m e n t❑ OUT.Or-SERVICE WELL ❑ GEOPHYSICAL WELL 0 - ❑ SOIL BORING 8 i ❑DESTRUCTION' [i I ' INTENDED USE TYPE OF WELL CON;TRUCTION 7PECIFICATION6 A r❑- INDUSTRIAL 11 OPEN BOTTOM VIA.OF WELL EXCAVATION VIA,OF CONDUCTOR CASING D LCI OOMESTtCMMVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEEU PM DIA.OF WELL CASINO V PUSUCIMUNICIPAL ❑D.MVEN DEPTH OF GROUT SEAL SPECIFICATION R IRRIGATIONIAG 1:1OTHER GROUT SEAL INSTALLED BY GROIrt Bf1AN0 NAME E ❑ MONITORING _ GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No S APPROX.DEPTH 1 4 6 LOCKING CHESTER BOXISTOVE PIPE S PROPOSED OONSTRUCTIONMNLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE T,OTHER j i EE I HE4EBY CERTIFY THAT I HAVE PREPARED TEAT APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REOULATIONS Of THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING.'1 CERTIFY THAT IN THE PERFORMANCE OP THE WORK FOR WHICH 1" THIS PEFUCT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SU"ONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEFiMR 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOMINIAN'e COMPENSATION LAWS OF Cr CAUFOI40A,� THE APPIUC MU�CALL. �"OtM IN ADVANCE FOR ALL REQUIRErISPECTIONS AT 12041488-24x7. COMPETE DRAWING AT LOWER AREA PROVIDED. �'`�� G Blpnad X_ / � Tlla _-- _ Date _ I PLOT PLAYA 10raw to 500141 Beale 'to ,y 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ' I ! 2. OUTLINE OF THE PROPERTY.OMNO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. !€ 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTtNa AND PROPOSED S. LOCATION OF WELLS WTTNN RADIUS OF ONE HUNDRED FIFTY FT. (� STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. . -. ..:.... ....... ... ... qp .. Z V 1 L Vn� i . ..... f ,h JUN.2.9 1998 SAN JOAQUIN CC1INTY � CJU'f'(�AGTF�'S�'t7VtCES [ffE DEPARTMENT USE ONLY f ` APp11aNlen Aoeapled 8Y Arae ' S Groin Impeclbn By ate P f p limparUen By -��^ Date !! Daatnretlen Inapeellen BY Date �� CemmerNO: I S f ACCOUNTING ONLY: AID# FACS JI siy 9 ;I PE CODES FEE INFO AMOUNT REMITTED CHECX ABH RECEIVED SY DATE PERMITISFAVICE REQUEST NUMBER INVOICE 2 µaoa Lib 42/aa[9 . .2k_D 1 I 0,,k Wooith Canr .FrmArn 17:4 111071