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r APPLICATHIN FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY.PUBLIC HEALTH SERVICr ENVIRONMENTAL HEALTH DIVISION P.O. ®OX 388,304 EAST 1NE:E)ER AVENUE, STOCKY'ON, CA 95201388 (209) 468.3420 • NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED 41. APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONE pRUCTiA AND/on INSTALL THE WOW DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS QF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIR JOB ADORESS/GR APN# 16865 Gawne Road clrr - Stockton, CA ONMENT OWNER'S NAME Michael McGranahan, Trustee $a. r PARCEL AL HEALTH DIVISION. L SIZE/APN# f ' P. 0. Box 5018 PHONE# 524-1793 CONTRACTOR i.� ^^TT 7� ^�o� ADDRESS P.Q.J.J��}{ 51, R10 V1S1-c1 uC�4 PHONE A707 374—M5 SUB CONTRACTOR O��-rt ADDRESS 94571. # I'- PHONE# , TYPE OFA LtAVMP; CI NEW_wrLL_r LIMP-ACEI4IEHI,7L WELL SYSTEM jCROBs-CONNECT REPAIR ❑❑N ❑RepslrPTH PUMP SET_ FIRST WATER LEVELOUT-OF-SERVGEOPHYSICAL WELL# ❑ SOIL BORING ❑DESTRUCTION: �f-WENDED USE TYPE:OF WELL CONSTRUCTION SPECIFICATIONS LI INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_101 p DIA.OF CONDUCTOR CASING`��A ..� A ❑ DOMESTICIPRIVATE I GRAVEL PACKIRIZE TYPE OF CASIN137STEELIPVC ^� U ❑ PUBLICJMUNICIPAL ❑DRIVEN - DIA,OF WELL CASINO 11 O 1 DEPTH OF OROLIT SEAS 1 81'ECIFICATION .�❑7 MONITORING ❑OTHER GROUT SEAL INSTALLED BY TaMAO _ .._..- GROUT BRAND NAME A nr4 MONfTbRINO r f GROUT SEAL PUMPED; Vee ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yw KI No S APPROX.x.DEPTH LOCKING CHEBTER BOxlBTOVE PIPE_ PROPOSED CONSTRUCTIONMRILUINO METHOD: MUD ROTARY AIR ROTARY S AUGER x _CABLE OTHER — I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION qN0 THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUtN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:°1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNM.' CONTRACTOR'$HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES ' THE FOLLOWING: •{CEIIT{Fy THA7 IN TILE FbRMANCE OF 7HE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Or. CALIFORNIA.' APPLICANT V$T CA 4 HOUR$IN ADVANCE FOR ALL REQUIRED IN TION$ 7 12os1 4as1423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slaned X Till ' Deta ' PLOT PLAN{Drew to SeNel Scars; to I. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPDSED 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. { EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2- DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED - S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY, _.._..i. -....,..E.- ..:'.... ....:..... -....i - j. .. .--.:.-..- .... -.--.. .1.. :.. NOV 8: 1998 _ ..,... .,.. ..gqN JOAQUIN COCIN r v _ FtJBLIG HE�a TM SEFit/f{'ES ENVIRONMENTAL H�AL?Fi DIVIS�C7N. ... ........ ....; - .. ................ ...........',......'..,..,.....s.....:....... 1 DEPARTMENT USE ONLY__ Appflcelfen Aeeapled By —. .. '�. - - ", 1�a `— r••-' Dele Aree GraV1 Irypecllon BY Date Purirp Impaction By Dole ' Deavtrctien lmpeel un'9 - - Date CommnNc - ) ACCOUNTING ONLY: AID# ""' - FAC# PE CODES FEE 1NT6 AMOUNT RFMfTTE4 CH #!CASH RECEIVED BY, DATE PERMITIeERVICE REOuEsT NUMBER INVOICE L4ICPA Pub,Health Sam-Enviro.173(3196) �>.. '� 1