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PERMIT APPLICATION FOR WEL4PUMP v -SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES I fl ENVIRONMENTAL HEALTH DIVISION r `^` P W BOX 388, 445 N. SAN JOAOUIN ST, STOCKTON, CA 95201.388 96 JAN 32 AN 11: 25 (209) 4583420 MGM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I; (Complete IN TTIpBntEl AFFMATION IB HERE BY TO THE BAN JOAMIN COUNTY POR A PERMIT TO CONSTRUCT AND/OR INSTALL THE NOR(DESCRIBED.THIS AFFIICATNIN IB MADE IN COMPLIANCE WITH BAN JOAGUIN COUNTY DEVELD MENT TITLE.CHAPTER -1116.3 AND THE STANDARDS OF BAN JOAGUIN COUNTY MOM H�/'EAAAA111LTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDREB&D1{J\W\!,/(Iii \�r I I 1 Z� I I I — 19 CITYR�PARCEL 8RF/AMI J / (/.Z OWNER'S NAME �✓r\�' /� �F"� ADDRESS / PHONE I ` cj d J�Dy SI I CONTRACTOR �V I IY l.i!-1Vl'1-Cti�W1(.v ADDPEBB YI C1/C'IU H'\H'LL G,,.1 LN:/6Sfsi3( (, mONEO�74_t BUB CONTRACTOR 1�11�P1 RU I'\ ADDRE88I 101 L� FW�(AaL1CI `gZJ� v PHONE I.s/a F>�t -G6I3 ulp I TYPE OF WEULMMP. ❑ NEW WELL ❑ REFLACEMENT WELL ❑ MONITORING WELL 0 ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CMH RCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I. J 0 New❑Rep.lr H.P. DEPTH PIMP SET—FT. FIIRST WATER LEVEL - O ITwE OF PUMP ❑ OUT-o"EmmE WELL ❑GEOPHYSICAL WELL I ` OM SOIL BORING 6 El DESTRUCTION: INTENDED USE TYPE OF WELL CONETRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM M.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O I ❑ woowN:/PRIVATE it ❑GRAVEL PACK/8121 TYPE OF CASING/STEELR'VC DIA.OF WELL CAGING D ❑ memmUNICIPAL li ❑DRIVEN DEFTH OF SHORT SEAL SPECIFICATION R ❑ IRRIGATION/AG '' ❑OTHER GROW SEAL INETAUJkD,-BAY GROUT BRAND NAME E ❑ MONITORING .I�O � GROUT SEAL PIMPED: M Y. 13Ne CONCRETE PEDESTAL BY DRILLER:13Y. ❑Ne 5 MEPTH APDX.DII LOCKING CHESTER BOX/STOVE PIF ,YXI ^1 I` PROPOSED CONEH M=N/DRWNO METHOD: MUD ROTARY AIR ROTARY AUGER CARIE OTHER 1,V 1 �-Pl\ �U\1� 5 � 1 HRMEY CERTIFY THAT 1 HAVE PREPARF.D THIS APPLICATION AND THAT THE WOR(WILL BE GONE IN ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES;STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIE8 THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOO WHICH j THIS ROBOT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORIUMAN't CONFIRMATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR B ONTIIACTING DENATURE CERTIFIES `k THE POLLOWI O: 'I CERTIFY THAT IN iN PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUGIECT TO WORKMAN'S C PERM N UWB OF CAU[M MA.' THE APPLI ANT MUST C NO UY IN ADVANCd`FOR ALL REO EWMQ CNONS AT12001 40 00 /4 41I".. COMPLETE DRAWING AT LOWER AREA PRO D. mPM X1" 1'11 RCI, RAM Skew I.SeNal 8W •1u r —�.AH CRMADB NEAREST TO OR SOUNDS& THE FRDn RY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL OVUM OR PPOMSED ------ "_ N MML N N. — —_ EXPANSION OF SEWAGE OWPOSAL BVSTEMS. { S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. {r WRIGHT ENVIRONMENTAL -----��_oN rHE POPERTY OR AG.OmING PROPERTY. CORPORATION HEADOU RT RS ICE$, INC, . j BUSINESS LICENSE#651501 4220 COMMERCIAL DRIVE,STS,5 / k I, TRACY,CA 95376 1 L. (209)833-0758 - BANK OP STOCKTON _ TRACY OFFICE L fl i TRACY, 90-1031211378 PAY Eighty 3735 9 y Nin ---___--_ - CHECK N0. --------------- -------------------------------------- (I:14f DATE ________00/100 TO THE THE SAN JOA_ AMOUNT S'I ORDER P'O• BO�U20U90UNTY PUBLIC HEALTH 1/30/96 5'44444####4###89.00 - OF .STOCKTON, CA?95201-2009 -- 1 ..F 119003735B' 2110i0371: Oi a ✓ D .241n605 — I I 1 1 ... HE H JR)P QF1UQ . µ�p6ed L3arin L4'ahau .. Go E.loth& rlr,Eg (subject.fo fie�o DVM my USE ONLY I AFPII 1H AeestM BY