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j. `° 4PLICATION FOR WELLIP.UMP PERM SA AQUIN COUNTY PUBLIC HEALTH SE SES ENVIRONMENTAL'HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON,CA 95202 _ (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompl@tf in Triplk*tol APPUCATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRSED.T11lB APPLICATION LB MADE iH COMPLIANCE WRtI SAN- ,IpAOU1N CDUNTY,OEVELaPMEHT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOS UIN COUNTESOMR',DEV 5 0 3 Ir A S T T E N Y A 5.T R S.E T CITY T R A C`f PARCEL 9CWAPHI 23 5-I GDVINT OF SAN TOAf1a VI1J ADDRE68122 E. we(3E AYE GrHFL00R pHONEr1D9 X68- 910 OWNER'S NAME 4TOC `*W, GA 9520 F 15 c H E N Y I Fl O N M E hI T A ADDRESe 22 5 H L'. G A LT'SS g 6 5 PHONE CaNTRACTOR VALLEY SpkimCs r- �g woDRE@B PMNE SUB CONTRACTOR TYPE o ❑ NEw wELL '13 REPLACEMENT WELL - (3MWATORINO WELL• ■ OTHER GEb'PP,013E ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR El VAPOR EXTRACTION WELL f J ❑N.©RWak H.P.- _ DEPTH PUMP 8E7FT. FIRST WATER LEVEL_„�,�� O ITYPE tl� F PVNIPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL.I ❑ SOIL BOWNe 8 ❑DESTRUCTION; A INTENDED USE TYPE OF WEll CONSTRUCTION SpECIFUCAT10Nf _ N ❑ INWSTRIAL ©OPBOTTOM DIA.OF WELL EXCAVATION Z- I DIA.OF CONDUCTOR CABING�J� EN D 1.1 A DIA.aF WELL CASINO O ❑ DOMEBTIClPRIVATE ❑GRAVEL PACIUSIIE TYPE OF CASiNG/STEEUPVC A DEPTH OF GRQ17T SEAL T0�A i. f=PTH SPECIFlCATION N A , R ❑ PUSLIC1MUNtC1PAL ❑OmVEN _ E ❑ IRRIGATIONIAG ❑OTHER .GROUT SEA1 INSTALLED.Sy GROUT SPAM NAME . ❑ MONRORINO�� GROUT SEAL PUMPED- ■Yr 13 N. CONCRETE PEDESTAL BY DRIlEIk 13 y- N. - 5 "I O F'I". LOCKING CHESTER SOXISTOVE PIPE . N APPROX.DEPTH A s CABLE GEO P R 0(3E PROPOSED CONSTRUCTIONMMLUNe METHOD: MUD ROTARY AIR ROTARY m AVOER OTHER SOIL AND CrROWADWAT EF, %KAB 5A''MI' 1140' I SAME - DAY A6Am0ONMENT I HEPESY CERrIFY,HAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUtN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING.'t CERTIFY THAT IN THE oEWORMANCE OF THE WORK FOR WHICH THIS PERMIT 10 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'@1 COMPQ1SATiON1 COMPRI@ATION LAWS OF CALIFORNIA.CAEIFO .• CONTRACTOR'S HLRING OR SUB-CONTRACTING SIGNATURE I THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORC'.FOR WHICH THIS-pemrT 18 MGM.I SHALL EMPLOY PERSONS SUBJECT TO WORIOMANLAW$ F AW8 OOF CALIFORNIA.' THE APPLCANT MUTT CALL 24 HOUM IN ADVANCE FOR ALL REOUIRED WSPECTtONf AT 12"1408-2422, COMPLETE ORAWma AT LOWER AREA PROVIDED. TId. GONLVL{ hNT kGEr►T D.. 10 Z9 9} I` Slar d X . T o 5 E P(i A A M A C-E PLOT PLAN t Mfrs to So. Sa@S lo Ia 4. LOCATION Of HOUSE WAGE DISPOSAL SYSTEM OR PROPOSED 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERSCOW EXPANSION OF SEWAGE DISPOSAL SYSTEMS- 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. @, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDWO FIFTY FT. 3. OIIAENSIONED OUTUNF.S ANO LOCATION OF ALL EXtffTWO ANO PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY. STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,ORWEWAYS.AND WALKS- S .[: .. ..._a. T ,T..;..�...G...H T : E P k A N..... ..... ...... .... :.......: s ....: pEPAIRIYI@IT U@E ONLY _ Applleatl.n Ao.mtd By c .. �Y Dat.. A. Grout Impasrten er - Oa.- Ptrnp lmveatlttn By Dat. I� ae.tnnllen fnep�tl.n By .. 4 ACCOUNTING ONLY: Atb/ FACS PE CODE@ FEE INFO AMOUNT REMITTIA CHEGK►A:AiH RECEWW IlY DATE PEIVATISHIVICE REQUEST MWERR INVOICE lZLl 4 •fib_ --:v .. E Pub.Health Serv.-Envira,173(i/97)