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15/ APPLICATION FOR WELUPUMP PERMIT PAYMENT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES P FCEI BLED ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 OCT 2 71998 (209) 468-3420 PUBLIC HAQUIN GUUNTy 1:017-REFUCDABLE PERMIT EXPIRES 1 YEAR FROU DATE ISSUED ENVIRON EALTH SERVICES ME'NTgI HEALTH D1VIgIOIV APPLICATION COUNTY DE EL MADE TO THE BAN CHAPJOATER 9IN COUNTY FOR A PERMIT TO CONBTRUCTIANO/On IINSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CH��A+,L�FER 8,-111 F.3 AND THE STANDARDS OF SAN JOAOIIIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS=APNF W• St(OV44 •+r A ftgf+In It)o W 5:x CITY K rot A _/1_ `.' 1 PARCEL BiZF/APNS OWNER'BNAME-- qG�V A(� �1�QV� ADDRESS Lr.J7 �� yVIIYN.O` /'FTG /'Yssoc.:cti�s.-s /Y�� p/��., /�•Ac�► PHONE. 519-z.tob CONTRACTOR ADDRESS_11co crJM)AUCs FJP, UCS PHONE FS7q-ZZ.Z-I SUN CONTRACTOR V V`� 610-id I ADDRESS A rz-�_IS_I+ LIP Li- UCI7ZO '^( p �PHONE/�7 3��-L915 _TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONAOWNO WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELLP (TYPE OF PUMP) 11Now ElRopoN H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-0F-SERVICE WELL ❑ OEOPHYSICAL WELLF br BOIL SORINO e ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS�`t A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 11,.AA DIA.OF CONDUCTOR CASINO—�L�--- O 11DOMESTIO/PRIVATE 11 GRAVEL PACK/SIZE TYPE OF CASINO/STEEUPVC �2.�NA DIA.OF WELL CASINO NA O 11PUBUC/MUNICNAL 11 DRIVEN DEPTH OF GROUT BEAL 3zj SPECIFICATION I L❑ rWt IR IOATION/AO ❑OTHER GROUT SEAL INSTALLED BY +V - flU GROUT BRAND NAME -I< �_ E VSI MONITORING �2GROUT SEAL ROMPED: ❑Y. Em. CONCRETE PEDESTAL BY ORILLER:❑Y. 49'No 5 APPROX.DEPTH D%--, LOCKING CHESTER BOXISTOVE APE s PROPOSED CONSTRUCTIONMAILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HMIVY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TMS PERMIT IS ISSUED,1 SI/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA-- CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN TIE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURED INSPWTIONS AT 120*1400J422. COMPETE DRAWING AT LOWER AREA PIIOVIDED. �1 Swwd X Title /< /1/JMI� //!L•rM n a tiA� DHA PLOT RAN IOrow to 801141 Scott 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 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 V4fNf UULDPI)QEONE HUNDRED FIFTY FT. STRUCTURES, o D - — �-_ DU WIEB NG 94-373-A15 z —� z w o A O m 0 z y A O O ' N V O `m Z m O ) N r • •� y O n F O A r — n — N o e C aux m A 1 O ® 2 I O 9 v l = I I z m n L — — —J NN m N 'n O D v 0 y N ; !n • A n •W y A Z Z ti A n A m D to o 0FOGS OF CURR • r Z > N o m p A A Z N < D (7 m S T O C K T 0 N S T R E E T 1LA y DEPARTMENT USE ONLY ' Ayplb�llen AeaiPled eY - - - •oto-�=�� - -�uw_-' •- •— Grein M pootlen By DoH Pump Inro.etlen ey Dole Dote owUuetlen ltwewtbn BY �j ��j, 1� /�,l ',1 / Q,,,�y,A��,�L� ��/O� /L��,�L��ry��,� CemmeMo: I1 b u�Rtl6 I9 L/1:TJ UL/ I�� •(tew I f FIIW/TL� /CIV1/ILII FY/L'11 ym fimwir 1p '^IV�6 tsslf, o aq ACCOUNTING ONLY: AID# PACO ' PE CODES FEE INFO AMOUNT RFIWTTED CHECKP/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3�U1 moi ' r Pub Health Serv.-EnvirO.173(1/97)