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ORIGINAL APPLICATION FOR WELLJPUMP PER S�AQUIN COUNTY PUBLIC HEALTH SEES RM P ENVIRONMENTAL HEALTH DIVISIONd N A L 304 EAST WEBER AVENUE, STOCKTON, CA 95202 /�� '/_ ` (209) 468-3420 LUN ppUNN 164 S5 66 �� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SP�g�c �`N Ho ISDN (CamAPPLICATION 188 MERE BY MADE THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSPRUECTIANOMIT INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB JMADE N COMPLIANCE WIN SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE CTANUAROS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADOMS$Mn APNI Si 51 PAG'1 F/C AVGEVVE CITY S'rL"G J�('Q/L/ PARCEL eIEEIAPNI IO Ff—I(.E/J-G/ OWNER'S NAME_ IV-3G' COe�'rGF 5%FNE AS JJd ADDRESS PHONE I ZV^/ 9S CONTRACTOR Ct�s/Q,e c�✓ctc //��, ADDRE68 Zt%ZyE L-l/4RAEie ucI 77,-5 o U RIO NEI e?L1�I' /�l._,, Sue coNTRAcroR ADORE99 �.C'77%/✓ 7 LACI RHONE I TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL i ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ❑ M.P. PTH PUMP B N.❑ J Rear ET FT. FIRST WATER LEVEL RYPE OF PLIMPI N -- G ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I BOIL BORING TEST Aj1Q//VY DESTRUCTION: T S INTENOEO USE TYPE OF WELL CONSTgUCT10N SPECIFICATIONS 11 INDUSTRIAL ❑OPEN BOTTOM GIA.OF WELL EXCAVATION A GIA.OF CONDUCTOR CASING D ' ❑❑ PUBLIC UNICIPTE 1:1 GRAVEL PACK/SIZE TYPE OF CASING/STEEVPVC R18UC/MVNICIPAL ❑ORVEN GIA.OF WELL CASINO D AAAA----....,�� DEPTH OF GROW SEAL SPECIFICATION R -tNIATRING 11 OTHER GROUT REAL INSTALLED BY GROUT BRAND NAME E MONITORING GROUT SEAL ROMPED: ❑Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ON. S APPROX.DEPTHGROW CHESTER BOX/aTOVE RPE PIIOrotED CONSTRVCNONNRWNO METHOD: MUD ROTAM---,K_pIR ROTARY AUGER CABLE OTHER 5 1 HE9E9Y CERTIFY i14AT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY, HOME OMR OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK MRNMICH THIS PERMIT 19 ISSUED,181HALL NOT EMPLOY PERSONS S JFCT TO WORKMAN'S COMPEN IATON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMA E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 NOUN; ADVANCE OR ALL REOMREO INSREOTIGNt AT IWMI 4"t 23. COMPLETE DRAWING AT LOWER AREA PROMD elan X Tills �iGE/Lrr Dae /v r Uo MOT N IDrnv Ie easel Brae 'le 1. NAMES OF STREETS OR T,.GI ING DIM TO OR BOUNDING THE PROPERTY. 4. LOCATION OF MUSE SEWAGE DISPOSAL SYSTEM On p ,MCEO 2. OUTLINE OF THE RbPES AN GIVING DIMENSIONS ANDXIS NORTH RECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. G. DIMENSSTRUCTURES, OVil1NE8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOIIED FIFTY FT. 6TRUCTVRE9,INCLUDING COVERED AREAS SUCH AS PATIOS,ONIVEWAYS,AND WAMS. ON THE PROPERTY OR ADJOINING PROPERTY, ,.... 7,6e G/1/✓/E'o�V%Y7 �'q ......:.. . ,.... .'. ' EHr use ontY APPlla.nen AccmW BY • V \- u-{ 11�y ml. .)' l ✓ I A, 0'. .In.P..I.BY D.1. b R p Impslmn Br O.a O/ Dn.4w11en IrnPaellen BY DNe ava CemmmH: ACCOUNTING ONLY: Not FAC! PE CODEC I E IND AMOUNT REMITTEDCHECK CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3F5 ( — 3537 is II OU ;Z Li ., 3535 3 Pub.Health Serv.-Enviro.173(1/97) ORIGINAL