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ARE <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 kyr <br /> NON•REFUNRRBLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUER <br /> IComplets In TtlpReaul <br /> LI <br /> APPL <br /> ION 19 HERE By MADE TO THE SAN JOAQUIN COUNTY <br /> III <br /> ' <br /> ITFPERMIT <br /> OCETI401X.y� <br /> E WITH SAN <br /> JOAQUIN COUNTY DEVELOPMEMTALE, CHAPTER 91115.AD THE SRNOARCSOF 9ANJOAOU N COUNTY PUBLIC SERUCEB,, ENNRONMEMA <br /> JOB ADDRESS/OR APNI (OCa m rT A JARr CITY S+(3LMFN } 0ROWN <br /> I� �y ((: ` PANEL 642F/APRI I f <br /> OWNER'S NAME •//��"rY •/+ / "\`IT\y,, . R4''jtJ�V AiRI \ Rw'*;A :1r ADDRESS m3lbiQ 14 — I/`I <br /> M\O, O+"\ . Ire cHbNEs 2�`F"Da3' 2 <br /> CONTRACTOR PT' \ '✓( Y�"`YSL�=\Cty1 `Vii - ADDRESS [�w V✓ OG\VsA P-A LOCI PHONE 5 'Z1/Y <br /> FLAB COMRACTOR_� . �r�l \P \ l`\V`) ADDRESS kiL �l � I'M ^T Q L1Ll 'T'^•' b"� PNONE I � 7� / 'L}J <br /> TYPE OF WELL/PUMP: ❑ NEN/ WELL ❑ RErlEACEMENT WELL ❑ MONITORING WELL 0 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑ Never 11 RsPelr H.P. DEPTH RUMP 8ET_FT. FIRST WATER LEVEL D <br /> RYPE OF R1MP1 ''7j <br /> ❑ OU -0LL ` <br /> TF-SERVICE WELL ❑ GEOPHYSICAL WEIt brSOIL BORING B <br /> ❑ D£FTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS L� p p q <br /> 11 INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION ��r '((' ORA. OF CONDUCTOR CASING, II <br /> ❑ DOMESTICIPRIVATE ❑ GRAVEL PACKISIZE TYPE OF CASING/STEEVP�V]CP. NYT DIA. OF WELL CASINO <br /> h M D <br /> ❑ PUBUC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL J 6 �},, SPECIFICATION NA \� R <br /> j❑ IRRIGATIONIAG ❑ OTHER GROUOSEALINSTALIEDRY� 1 'rtaVklt j� ( �f., BMW BRAND NAME �r\TV \'N E <br /> 42E MONAORINO �A, 1,{ L y BMW SEAL RUMPEO: L$Yee [] No TT CONCRETE PEDESTAL BY ORILLEN ❑ Yr le S <br /> APPROX. DEPTH CJ Li T 1 S LOCKING CHESTER BOX/STOVE RPE <br /> 5 <br /> PROPOSED CONSTRUCTION/CRWNO METHOD: MUD ROTARY AIR PATARY AUGER. ,1( CABLE OTHER <br /> 1 HIP FRY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILLBE DONE IN ACCORDANCE MATH SAN JOAQUIN COUNTY ORDINANCES, STATE LAW e, AND RULES ANO <br /> REGVIATIONS OF THE BAN "AWN COUNTY. HOME OWNER OR LICENBEC AGENT'S SIGNATURE CERTIFIES THE MULDWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR( FOR WHICH <br /> THIS PERMR IR ISSUED, I61RALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOO WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORIMAN'S COMPENSATON LAWS OF <br /> CALIFORNIA.'.' THE APPUCANT MUST <br /> /,-C//1�UL 21 NOW IN ADVANCE MR ALL REQURED INSPECTIONS AT ItOSI AY-11 1. COMPLETE DRAWING AT LOWER AREA PROVIDES.. <br /> SlwEed X �l//J M/ i /'-1 � I�✓�/:1" I' Com - Title amr' / 11 .x- r Date yQ <br /> PLOT PLAN IDree to Scale) Style to <br /> 1 . NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR rnoMSEO <br /> S. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEtRfAGE DRP09AL SYSTEMS. <br /> O. DIMENSIONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN MONS OF ONE HUNDRED FIFTY FT. <br /> STRIUCTURES, -IUrnNn rf1VFRIM AMA P n ...e w - - -- -- - - -- <br /> I} °RORRftl. <br /> N <br /> E ANCRET s' <br /> cµ I <br /> WELL E ' <br /> EENc. <br /> ..? <br /> O :G. <br /> Ou <br /> i <br /> BUILDING <br /> sR./M..c <br /> FORMER USE o :. <br /> L SPI <br /> AS <br /> �AMNI :G /MINT :cuM <br /> y <br /> PER <br /> s a RET s . . <br /> OAK <br /> LEGEND_ APPROXIMATE EULE <br /> FOR a SOIL BORING LOCATIONS <br /> MAN Ia GROUNDWATER MONITORING WELL oNR /11Cas1 naffs iN10 e <br /> ,.,EMAE o on,; R.na uW�, uuo�. BIN - <br /> 0 PROPOSED BORING LOLArNiq FARMER <br /> PRPER . <br /> 610 KTHLOOODr4 ELOPER <br /> A <br /> I <br /> SITES PLAN . . _ . ... . . . . ...... <br /> FIGURE 2 <br /> oEVAR,MERT USE ONLY <br /> Applleatlee Aa emete l By oAA� to v Date ' / , .L � Area <br /> IF v <br /> Ovate Inspection 8Y Data Pump Impaction It Date <br /> Orbmllen lrseectb Br Date <br /> Commenn: <br /> ACCOUNTING ONLY: AID/ FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKFUCAIIH RECEIVED BY DATE PA MITISEANCE REQUEST NUMBER INVOICE <br /> / <br /> PUb Health Sew. - EnvirD. 173 (1 /97) <br />