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APPLICATION FOR WELUPUMP PERMIT ujo' "/ SAjbAQUIN ENVIRO MEN AL HEALTH DIVISION�ES 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE CAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITII SAN JOAOUIN COUNTY DEWLOPMEW TITLE CHAPrER 5-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY MA/WC/HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR AEN# b % V PARCEL BIZEJAPNN SI7 Se 1lAyD yClaa �iN De e. as /s CSb�Ds 900 Pewe)I Sm A /07 F7r OWNER'S NAME CIO T1 ald T R �L 4 LP( 'NE F ce P:ADORE88 ✓i/7� �' 4 4y608• /827 PHONE I ,S/O -6s]-54T00 CONTRACTOR ADDRESS LICE PHONES 6 00 a at oho) Dad sue CONTRACTOR 11)e e.ks Dr 11,'y4azg( l�w,-.�.� 00ADDIEC& 6e y..-Ho�e1 fA4.rH73 Dice /7763// PHO/NE 1707-8.73 TYPE OF WELL/PUMP; IGS NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ® OTHER G GCI FXTLre.1-a10..J ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBBCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ U NOl O ❑Nev❑Rep.4 N.P. DEPTH PUMP SET 80 FT. FIRST WATER LEVEL O (TYFE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ OEO%IY6ICAL WELL# ❑ 601E BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION /ya DIA.OF CONDUCTOR CASINO A)1A D ❑ DOMESTIOR'18VATE ®GRAVEL PACK/BILETYPE OF CASING/6TEEUPVC SC{'f 60 PYG DIA.OF WELL CASINO O ❑ NI A CAMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL .00 y SPECIFICATION L 1 R ❑ IRRIGATION/AG �// 1�3/ OTHER GROVE SEAL INSTALLED BY �rJ l e r GROUT BRAND NAME A)9911 L o e' EJHI L E ® MONITORING��(TT6CT"�Ps-I GROUT SEAL PIMPED: ®Ys OR. CONCRETEPEDESTALBYDRUYN®Yw ON. 5 APPROX.DEPTH 90' LOCKING CHESTER BOX/STOVE RPE 1/eS S PROPOSED CONIMMUCTIONIDNLUNG METHOD: MUD ROTARY_AIR ROTARY AUGER CABLE— OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AM RULES AND REGULATIONS OF THE CAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONI ACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS IBSUEU,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAW$OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HO S I/L ADVANCE FOR ALL REQUIRED IINSMIR NrSS AT 120111401141422. COMPLETE DRAWING AT LOWER AREA%1OVIDED. sIa^ed x ��'/I I - TIG. 1 ">Y Pro i P A T Ma-77a P /' D.te /7h k PLOT PUN ID..w to S.J.1 Bc.b 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF"OUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE KICKArY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINE$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. " J R p 17 �t'Q C.� e cC �A�lS � /A FEB 2 3 1998 . . . ..... SAN JOAQUIN COUN 1 DEPARTMENT USE ONLY PUBLIC HEALTH SERVICES / ENVIRONMEI L Tb SION Avvllc.tlen Ace«ted BY Da. ' M.. 7 G-. Inev«Gen By D.t. PumO I..P«ti.n By Oae Oa.a«e.n Imn«0on By / Dae 661%) 011. Finn/ / ACCOUNTING ONLY: AID# PAC/ PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASII RECEIVED BY DATE PERMTISIAVICE REQUEST NUMBER INVOICE D p10 Pub.Health SEN.-EnvirO.173(1/97)