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.. PLICATION FOR WELL/PUMP PERMI-0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 RON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED D rJ_ �a13 (Complete in TIIpReole) 11 I I ' APPLMATION 19 MERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE MW DESCRIBED.THIS APPUCATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TRUE.CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Joe AODREsaroR APN/ J 3"1 G C� S ��`�-`� �1. �-"' a"'I 1 �{- .L. 1�,, 1T /1 CITY `J-�CK-T'' N PARCEL SIZE/APN/ OWNER-9 NAME w(HO'�fXl- � LCB I�U>a/.QJLY/.lOOG ADDRESS fl.O. 13d4 8?.I. 1�1Riv.-I�c..ca, GA453 nroNER CONTRACTOR Ke G G ORI LL MAMIG ADDRESS 950 tWe PHOzNsE I760 SOT— �LA!f]UN ADDRESS L9Zo GLL C-1-K. i"CR LCASA °PHONE/ 9L9 TYPE OF WELI/PVMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J (TYPE OF PUMP( ❑New❑ibedr N.P. DEPTH PIMP SET Ff. FIRST WATER LEVEL p ❑1 OUT-OF-SERVICE WELL ❑ OEOPHYSICAL WELL R Im SOIL SONNO N uaF\ ❑DESTRUCT: -'2 S � IA fe- (�( '�"�p`* �zt B INTENDED USE TYPE OF WELL CGNSTRUCTION SPECIFICA1I0M8 A 1 ^' ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D NIP, ❑ DOMESTIC'RIVATE 13 GRAVEL PACK/SIZE TYPE OF CASINGMTEEl PVC DIA.OF WELL CASINO O ❑ PUBLIC/MUNICIPAL ❑DNVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY BMW BRAND NAME E ❑ MONRORINO GROUT SEAL PIMPED: 13 Y. [IN. CONCRETE PEDESTAL RY DRILLER:❑Yw [IN. S APPROX.DEPTH LOCKING CHESTER BOXIBTOVE PPE S PROPOSED CONSTRtMIiONRNeLUNO METHOD; MUD ROTARY AIR NOTARY AUGER CABLE OTHER I HEeENY CERTIFY THAT 11PAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND SEGUUTION9 OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WOM FOR WHICH TRIS PERMIT 19 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA: CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAM-S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANTjMUJIT TCC)A/LLL 2224 HOURS IN ADVANCE FOR ALL REQUIRED IM MP TIO NS AT CMHN 400J 20. COMPLETE DRAWING AT LOWER AREA PRO Sler.tl X `��J�/`—� Tlla - T' ycA O•ta ! of D —. OT PAN 101•w to BPMeI 8••b 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOLI ONO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE OISMSAL SYSTEM OR PRICIPOSED Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AN NEN"M DIRECTION. EXPANSION OF SEWAGE DIGMSAL 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,ANO WAL(S. ON THE PROPERTY OR ADJOINING PRUPERTY. JL a 0c) Q- 1 131 4 DEPARTJiT-UMONLY A,,11—Ib .: 0•1• Oren M•pevlbn Bv_. Dn Rn•.P Ingeetlen wO•M1 Do•trutlen 1 r 11—BY O.1• Cnmmem•: ACCOUNTING ONLY: AID/ FACT PE CODES FEEINFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PERMIT/STRVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(1/97)