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1 - XPPLICATION FOR WELL/PUMP PERF SAV( OAOUIN COUNTY PUBLIC HEALTH SLICES ENVIRONMENTAL HEALTH DIVISION ` 304 EAST WEBER AVENUE,STOCKTON, CA 95202 = (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete In TTIplk9tal APPLICATION 18 IIERE BY MADE TO THE VAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.Title APPLICATION IS MADE IN COMPLIANCE WITI/SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 0-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTII SERVICE@.ENVIRONMENTAL HEALTH DIVISION,- $(O EAst NIAGN0LIA 5TRI- ET CITY ST0cI%T0N `~ JOB AbbRESe/OR API/ PARCEL SIZE/APNi OWNEn'e NAME .5ToGI'll row DEVELOPMENTAL CTR, AODREee SI0_E•Ma�Mo�ia Si',, StOCIIt•ovl- PIIo;N" 09.948•}411 VIRoNEX Ilst c Drive CONTRACTOR ADDRESS Foster Clstys . CA 944oym,. }0592-+ PHoNEo415.296.1066 SUB CONTRACTOR ADDRESS �,( LUCS PHONE I TYPE OF WELL/PUMP: 11 NEW WELL 11 REPLACEMENT WELL ElMONITOMNrI WELL I [E OTHER rr t O P r e 6 c 1 H y jro F N h c IL ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRIOBS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I )OC R t j 0115)J II VR'E OF PVMPI ❑New 1:1Rep 1, H.P. DEPTH PUMP SET FT- FIRST WATER LEVEL 0 ❑ OUT•OF-eERVICE WELL ❑ GEOPIIYSICAL WELL I Cl SOIL BORING S ❑DESTRUCTION. INTENDED USE TYPE OF WftL A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION NA DIA.OF CONDUCTOR CASINO N A 0 ❑ DOMESTK:/MVATE ❑yGRAVEL PACK/81ZE TYPE OF CASINO/8TEEL/PVC N A •DIA.OF WELL CASINO N A 0 11PURLICMUNICIPAL 8 6MVEN DEPTH OF GROUT SEAL 45 lest SPECIFICATION NA R �❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY V 1 RR O W E X OROUT BRAND NAME r-yNe U MONITORINO OnOUT SEAL PUMPED- ElY.- IN- CONCRETE PEDESTAL BY DRILLER.[I Yea L!7 e S APPROX.DEPTH 5 T r e e•r LOCKIHO CHESTER BOX/STOVE PIPE NO S PROPOSED CONSTRUCTION/DMLLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER D i t e C t' F1101. I ItE9FRV CERTIFY TIIAT 1 IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL @E DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORUINANCF.9,STATE LAWS.AND MULES AND SFOULATIONS OF THE SAN JOAOUIN COUNTY, HOME OWNER On UCENRED AOENT'e SIGNATURE CERTIFIES THE FOLLOVNNO:-1 CERTIFY THAT IN TIIE PERFORMANCE OF THE WORK FORWW" TISK PERMIT 18188410,1 81/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPWNeAT10N LAW@ OF CALIFORNIA.- CONTRACTOR-9 HIRING OR OUB-CONTRACTINO SIGNATURE CERTIFIES TIIE FOLLOWING- 'I CERTIFY THAT IN TIIE PERFORMANCE OF THE WORK Fon WRAC"THIS MWArt 18 ISSUED,I @HALL EMPLOY PER90NR SUBJECT TO WORKMAN'-COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 11 HOUR41 IN ADVANC9 FOR ALL REOUNtWO INSPECTION/AT 12001 44W-3422, COMPLETE DRAWING AT LOWER AREA`PROVIOED. elpn.e X ! �• In This To s E.P li RAM A b L 1117 O O R KOt PLAN(Drew to @aelal se«. 1 n •to 1. NAMES Or STREET9 On ROAOS NEAREST 10 OR BOVNDINO THE PROPERTY. 4. LOCATION OF"OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I. OUTUNF.OF TIIE rtOPEr1TY,OMNO OIMENPIONO AND NORTH DIRECTION. EXPANSION OF BEWAOE DISPOSAL SYSTEMS, 9. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTOM AND PROPO8E0 I. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. 9TnUCTUREe,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOININO PROPERTY, . 7F� bbM/ME/1T USE ONLY Aepeaellen Aatnrpted 9T � DN1/9� Area Oreul Inapeellen By DNe Rnl,Inopeetlen By r Dole r n—tnreNen Impeelbn By Date Cemmrena• ACC OUNTINO ONLY: AID( FACS PE CODES FEE INFO AMOUNT REUWSTTto HEC !CASH RtGOVEO 9Y DATP P9e6"T1401VICE REGUEST NUMBER INVOICt Pub.Health Serv.-Elrviro. 173(1/97)