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PAYMENT PFf"'EIVED APPLICATION FOR WELUPUMP PERMIT OCT 2 71998 SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION Pusu"j0AQuINcouNTv 304 EAST WEBER AVENUE, STOCKTON, CA 95202 ENv1RQNWNf^i HEALTH is`HDrvSION (209) 468-3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROU DATE ISSUED APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH/SAN JOAQUIN COUNTY DEVELOPMENT / W TIT LE.CHAPTER 9.1115.3 AND THE STANOARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.. JOB ADDRESWOR APHE 'IJID P—%+ SPT" 5+%rt A CITY—. R,�C)IA ,�II �7' PARCEL 91ZE/APN1 C •� OWNER'S NAME AA�mldt 1 kAt f MCSN VA ADDRESS (c)(0 W. S C w S'�" � C,-, RHONE• ✓ 9%- 3m) CONTRACTOR lft�- ASS£1tLLX+25 AooREes xr S"-Z—L7-1 SUS CONTRACTOR V 1 W IAVaitm ADORESSP0 Box 5QWp otisk PHONE f � -Ko LSLIO#_p PHONE TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CigSs-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F •/ RYPE OF PUN% 11 Nae ElRepoli H-P- DEPTH PUMP BET—FT. FIRST WATER LEVEL O ❑ OUT-0F-SERVICE WELL 11OEOPHYSICAL WELL# *$OIL BORING ' 9 ❑DESTRUCTION• INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS }�1„ A 11 INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION `� CONDUCTOR CASINO ` `V A D ❑ DOMESTICNRIVATE 13 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF Nf7� /VR( O ❑ PUSUCAMUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL (60 SPECIFICATION N A 9 ❑ IRRIOATION/AG ❑OTHER GROAT SEAL INSTALLED BY -f 1rt~, WA- GROW BRAND NAME-4�A�nilt. C,E•1µ^-& E 0MONITORINO GROUT BEAL PUMPED: ❑Yee ON. CONCRETE PEDESTAL BY DRILLER:11 Yee 1�Ne S // APPROX.DR"" COQ+((�� LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIDIELUNG METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HMSY CERTIFY THAT I 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 SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURED NSPOCTKINS AT 12081 4880825. COMPLETE DRAWING AT LOWER AREA PROVIDED. q*wd X() n M.�� 1-> TINe j?An M/LMQe/l One PLOT PLAN(Draw to Seale)Seale 'to 1. NAMES OF STIEET8 OR ROADS NEAREST TO OR SOUNDING 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 WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ET u G NUMBERRIMING 94-373-Al5 q ® 0� u Z T Z O G 0 A C O Z p 0 ) ... mo z N 1/1 m Q O A m m r w n Ae I • � G F ti - I mo F _ _ a o x N m asgl m a m C T s I O ® 2 I p Qq mI I m F m 7 L _ — — J ® p � a o N N m y O _ pvmm F O F n' Z Z w m Zm ? ~ D N • � r G � c Z to Z m I ti m 1- N o r O N p F • N TI ' Z N D EDGE OF CURB O m s 0 p M Z A .T7 Z N < f mo Z < m mm _ m o S T O C K T 0 N S T F E E T i I az m 0 A DEPARTMENT USE ONLY 'L1 Grew Mepeetlen By Dote PI p Ineoemlen By Dote — Deavraalen I svaetlun By ! � ,T Lr, (/�� y� 1,) ,'1 (7 MIX Ay/, f ,/�� 1D1ale -'1� CemmerNa: '71 M4 L /t l QUVIA'n P.SI X V��`� A65amt� riAL 11 jLiLi w- n' ACCOUNTING ONLY: AID# FAC/ PE CODES FEE INTO AMOUNT REMITTED CHECK#ICABN RECEIVED BY DATE PEPAIT/SERVICE REQUEST NUMBER INVOICE b 1 - 4 a. Pub Health Serv.-Enviro.173(1/97)