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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMTENIT ENVIRONMENTAL HEALTH DIVISION :e r� rF 5rw- 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 DEC 31 1998 MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICDmpM4 IN TIIpRe;id L 4:� lI it LIDO IN NITINV 111 11 APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMA INSTALL THE WORK DESCRICEIS R111S FPPOCATJOt3(I6LTI I W COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT yTITLE, CHAPTER 9,.-11115..3 AND THE STANDARDS OFFSAN ��JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL NEAT SIGN, JOB AODRESSroR(�APNF JTi tt:l / tv��[.,`ir (9 L©\ 1,7%V) .1cooC '.;MSL sof CITIFY J��{U(,' h�/� �� i � ,, . ,iPARCEL SRE/APNI OWNERS NAME{^y1"iIy J�C:p� .170�;s7[:U1 `. Y�� V�YL (Jj �\ I`4 bt1F. ADDREBB 7Z N . �I LbFIN`.i�GF �TG""I PHONE 937• - Qyli f CONTRACTOR ' ( I V'{ , 1! I �S(�yClL a 4 v. ADDRESS I r �f� PCL t`4 �� I`V y�� UC0 (,� PHONE 0 SJR • - ZL� 4 SUBCONTRACTOR VJw �J'y�'\ k\\ • --L ADDRESS PV 60>� al _ �1T1 VS�CIl NC) zz?C 4 PHONE ih%F��'`(— l � l,.� TYPE OF WELLJPUMP: ❑ NEW WELL 1❑' REMCEMENT WELL ❑ MONITORING WELL I 11 OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSSONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑ Have ❑ RePNt HIP. DEPTH PIMP BET_FT. FIRST WATER LEVEL O TYPE OF PUMP) ❑ DVI-OFBERVICE WELL ❑ GEOPHYSICAL WELLN OIL BOFSNO S ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SNNINNIFF.PECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA, OF WELL EXCAVATION NNN, ��Cpp±,nn,, DIA. OF CONDUCTOR CASING NA O ❑ DOMESTICIPAIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASINO/STEEU .•y(t DIA. OF WELL CASING A, �A/A G ❑ PURLKRAUNICIPAL ❑ DRwEN DEPTH OF GROUT SEAL 'yl.J T SPECIFICATION 1 � yYLl, S 11 IRRIGATION/AG ❑ OTHER GROUT SFAL INSTAURIT StY 1"s L AMV t P; �J'� GROW BRAND NAME VLF%kf� Ot'I N, LvWy E LW.IONTORIND �y t n 1 GROUT SEAL P UMPEO: Jp Ys ❑ Ne CONCRETE PEDESTAL BY DRILLER: ❑ Ys elm* 5 APPROX. DEPTH is LOCKING CHESTER SOX/STOVE PP: 5 PROPOSED CONSTIRUCTONNRWNO METHOD: MUD fIOTARY AIR ROTARY AMER CABLE OTHER I HE9EBY CERTIFY THAT I HAVE pRPARO THIS PPRJCATMN AND THAT THE MRC WILL BE GONE D ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES. ;TATE 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 PERMT IB ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT Ie ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT TO WORMAN'S COMPENSATION "We OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOWLS IN ADVANCE FOR ALL REQUIRED INSPRT10NS AT 1200I144S-SWIM=. COMPLETE GNAWING AT LOWER ARA PROVIDED. SlProd X sl �- / This /1, ROT PLAN IOtow to Scafel Scale to 1 . NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OWUNFIT AND LOCATION OF ALL EXISTING AND PROPOSED S, LOCATION OF WELLS WITHIN MOUS OF ONE HUNDRED FHTV FT, STRUCTURES, INCLUDING COVERD AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. pr.I P A`5 G'4 o BAR uJAs1i San ,Jecg�. oY NYa Fit Z set bcr ?[ DEPARTMENT USE ONLY nv�ven Rpa a Da. I � L 1 �" V� Area ect Y _ -- — L Dote Peep Inopatbp BY Dote D I • HenRmpeetlpp Y net@ comment. N ��R �m >�UM CA-NN1 VE sT"W'r� euve iv) eat1s pv-c s ACCOUNTING ONLY: AIDS FAC# PE CODES FEE INFO AMOUNT REMITTED CHECKF/CAS" RECEIVED BY DATE PERMIT/SFAVICE REQUEST NUMBER INVOICE Pub Health Sew. - Enviro. 173 (1 /97)