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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (C9mp1919 In TrIpDent9) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESWOR APN# 20516 Flood Rd. CRY Linden PARCEL BIZE/APNP OWNEn•@NAMEMelvin & Anthony Gondolfo ADORES, 20516 Flood Rd. ,Linden PHONE• CONTRACTOR Purviance Drillers, Inc . ADDRESS POB 64 , Linden uc# 377923 PHONE, 887-3554 BUR CONTRACTOR ADDRESS 115 Z- J UC/ PHONE 9 TYPE OF WELLMUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL E 1 ❑N. AA4,Wr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI install well sea4 OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 ❑ DOMESTICS'RIVATE ❑ORAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING 0 ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME f ❑ MONITONNO OMLIT SEAL MIMMO: ❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Y.. []No S APPROX.DEPTH LOCKING CHESTER SOX/BTOVE PIPE S PROPOSED COMB TRUC TION/DMILINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEgEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TILE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERronmANCE OF THE WORK FOR WHICH T1418 PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORMA.' CONTRACTOR'S HIRING OR 8U@-CONTRACTING SIGNATURE CERTIFIES THE FOLLO '1 CERTIFY T HE PERFORMANCE OF THE WOPK FOR WHICH THIN PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOPKMAM'S COMPENSATION LAWS OF CALIF A.' T CA V T CA 21 HOURS IN ADVANCE FOR ALL AWOMFD INSPECTIONS AT 12091,« ET -TN2l. COMPLETE DRAWING AT LOWER AREA PROVIDED. BIS„eA X T1t1. Corporate Secretary Date 10/26/98 PLOT PLAN(M—to Bo.I.I S..le to I. NAME@ OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,OIV*M DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAOE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EX19TWO AND PROPONEO S. LOCATION OF WELLS WITMN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURE@,INCLUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAY8,AND WALKS. ON THE PROPEHTY OR ADJOINm PnopERTY. / Y ... E ....;.. .:. ' ... ; :. '. jr , .... OCT' 2:7 1998 1 ' I ..�t�fV1F;Cflifk.`�iidTai:1::r,l.i i`!C1NI�IGP� W 1 01►AATMFNT USE ONLY 0370 Appll-0—APoepld)By. ' _ /�� Do. A,-- Grein IMP-0—By D.te Pump In.pd;llen Sy ! ��1�'44,-4� i' —r, 2C.I— Oe.f—flon Irwnd:tlon BY O.Ie CommdH.: ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED L K# ASH RECEIVED @Y DATE PBWIITISERVICE REQUEST NUMNFFI INVOICE .o �� a l �, �, .