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SAIW1PPLICATION FOR WELL/PUMP PERM pAYMIVEp AOUIN COUNTY PUBLIC HEALTH SEW-CES FELE ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 NOv MON-REFUNDABLE PERMITT,EXXP AES 4 YEAR FROM GATE ISSUER SFN SOHap jH ICamplau In Triplicate] PU NMENjAL APPLICATION IB HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WOR(DESCRIBED.THIS APPLICATvMNo18 MAGE IN COMPLIANCE WRIH SAN IQFC /, JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. / JOB AOORE88roP API/ / / / �L/��t CITY srC/G IC rC7/� PARCEL SI2EIAPNt OWNER'S NAME �''�I{I�L�Q(J/.�I (}�L-r� (-;J�CGF ADDIIE68 s^�S'E �YI3•J_i tI C //�1f �3 PHONEt zU / n7S yjU•�� CONTRACTOR 2�/Zr/' Lr'/"�.�.�i ADDRESS uct-�7/��cl pH Hee -VS 7t Bub CONTRACTOR ADDRESS { 11CI PHONE 0- TYPE OF WELVPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL! ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL t J ❑ RYPE OF FV MPI N.❑Repelr N.P. DEPTH PUMP BET-FT. FIRST WATER LEVEL G ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL t .SOIL BORING ❑DESTRUCTION: TZ7 �.) INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONO A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p ❑ DOMESTICA'RIVATE ❑GRAVEL PACK/BILE TYPE OF CA61NGMTEEI/PVC DIA.OF WELL CASINO p R❑1�-yyPVSLICRAVNICIPAL ❑DRIVEN DEPTH OF GROW SEAL SPECIFICATION R IRRIGATION/AG ❑OTHER BMW SEAL INSTALLED BY GROW BRAND NAME E MONITORING GROUT SEAL PVMPEO: ❑Y.e [IN. CONCRETEPEDESTALBYDRILLER❑Yw [IN. 5 APPROR.DEPTH LOCKING CHESTED BOX/STOVE RPE S PROPOSED CONeTRUICNONnMaLMNG METHOD: MVD ROTARY_ AIR P0TAPM AUGER CABLE OTHEfl I HERERY CERTIFY THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AOENT'6 SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFOnMANCE OF THE WORK FOR WHICH THIS PEnMIT IS ISSUED.10IIALL NOT EMPLOY PERSONS 990ACT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING 09 SUBCONTRACTING SIGNATURE CEWIFIE6 THE FOLLOWING: .1 CERTIFY THAT IN THE PERFORMA E OF THE WOR(FOR WHICH THIS KAMM IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- TNNTJJJ APPLICANT MUST CALL M FOURS ADVANCE YOR ALL REQUIRED INSPECTIONS AT 12001 468J 22, COMPLETE DRAWING AT LOWER AREA PnO D SI,v-I X_%/'/',/(+ - �l nG. iOE.VY' D.I. C7' ROT N 0.le SeY.I&.1. e 1. NAMES OF STREETS OR MADS NEAREST TO OR SOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On ITIOPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. 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,AND WALKS. ON THE PROPERTY OR ADJOINING PROPEnTY. ..5'c�E �AT/.r G'.v'r/i>n-^rs - rr+-vv�iY.1-rpt l Err�`�K F.e✓%�s '. c co . . L N'✓�,E-o�v' YEn,�--4 .A d.r /iVc O��LT 'lL �. �. L.__ '... !. .. .. .... ......' r ENT USE ONLY I _<V '\ - D.I. APPIIveHlen AvvePHed BY O GrvU In.PrrOen By O.t. P p In.P«nen BY O.b Dvancllen Imvmllvn Br Dele Cemme.nc ACCOUNTING ONLY: AID/ FAG PE CODES EE IN O AMOUNT REMITTED CHECK ASH RECEIVED BY DATE PER AITISERVICE REQUEST NUMBER INVOICE -3ss o l� — 3Ss� l5 7 353 3 Pub.Health Serv.-Enviro,173(1/97) Irl I NTn A�I-LL IFWYI FILE COPY