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APPLICATION FOR WELLIPUMP PERMIT �y SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388, 904 EAST WEBER AVENUE, STOCKTON. CA 95201388 1209) 4663420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P APPLICATION IS HERE OV'MADE TO THE SAN JOAOUIN COUNTY FORA PERMIT TO CONSTRUCTI ANDIOnI INSTALL OHF WORN DFSCRFUO-THIS APPLICATION IS MAO,IN COMPLIANCE W V N SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3{1AND THE STANDARDS OF SAN JOAOUIN COU TTY Mn1.IC IMALtH SEGVICES,ENVIRONMENTAL HEALTH nMS10N. JOB AGGRESSOR Am,_,I S3 Ir y1 in V1 e r L 1 If ( I I, ' < CIT!—m I Q RI�c A i 1 y,/ /' J I, L 1 PARCEL PIZEIAMS p'F] '] ]L OWNING NAME - 1 �"� CPE�'/'��T-Q. Cf� �rVF� \I1<,Sf II ,I.SJ VAl1�Y I 'I brCle RIONEF JGl_L2/V JJ IE'— ADDRESS_ CONTIUCTOA ANYln i ie (req C Hy�r�gMf p /�'� / 71�+' Annnfr.P / I✓ MQY[�L L� #A ucl 6 2 Z 7 PHONE F � �QVA O PVB COMRACTOR� 1 ARVRfSP. C.®ox SCC-rghvA S( UP' kQ 417 PHONE13 ) j �(J ^9�✓+e TYPEOF WELVR)MP: ❑ NEW WR,L ❑ nFR ACFMFNT WFIL ❑ MONO OOINn WTIL l _ ❑ OTHER ❑ PIRIAIUT1ON ❑ WfIt PYPITMnFPART ❑ CMRS CONNECt AFPMa ❑ VAMPfXTMCTION WELL)__ ❑ N.❑Medr N.P. DUPE OF RUMP) HIM if RUMP art__FT. FIRST WATER LEVEL _ n 1 ❑ OULORSEFT"CE WELL 11 GEOPHYSICAL WELL 9 11 FOIL BORING I, KDESTRN UC1HON: Of 1 �YYf MOft 11-v1FI wfoE1 10 1 1/ IC 6114W I,i,�1�Cs1'1A ;i INTENDED UEE TYPE OF WELL CONGI➢UCIION SPECIFICATIONS - - - A ❑ INOUSTRAL ❑OPEN BOTTOM VIA.Or WFI I FXCAVATION VIA.nr CONONC1On CA51Nn /. ❑ DOMERTIGRBVAIE ❑DRAWL PACKIPIZE TYPE OF CAIIINn/FTEEL/PVT, DIA.OF WELL CASINO n ❑ MSLICMUNICIPAL ❑DRIVEN DEPIII OF OnDIIT SEAL SPECIFICATION q ❑ INRIGATIONIAG ❑OTHER GROAT SEAI.INSTAL)TD RV GMVI PRANG NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Y— [IN. CONCRETEPEOESTALSYDRLLFn:❑Y- (IN. S APPROX.nFFTH LOCKING CHFPTEn PDXInIOVE RLF , PROPOSED CONSTRUCTIONIptlWNO METHOD: MUD ROTARY Ain RDIARV AUSFR CABLE OTNFD I HERESY CERTIFY THAT I HAVE PREPARED THIS wPY+UCAl10N AND THAI TIrF,WORN Will PE ONME IN ACCORDANCE W1T4 BAN JOAMIN COUNTY ORDINANCES.STATE)AWS.AND RULES AND REGULATIONS OF TIIF SAN JOAOUIN COUNTY. HOME OWNER On LICENSED AGENT'S SIGNATURE CERTIFIES TIIE FOLLOWINO:'I CERTIFY THAT IN THE PRrORMANCE OF THE WORK FORWHICH TIIIS PERMIT HS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COMRACTOR'S HIRING On BUN CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOD WHICH THIN PERMIT IN ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION)AWB OF CAUFORNIA.' THE APPLICANT MAST CALL 24 HOURS IN ADVANCE FOR ALL I EOURFIR INSPECTION*AT 12"]ASSJr1}a, COMPLETE GNAWING AT LOWER AREA P IGIADED. elvnne K Ito" A MiI� PHI. � P F}Fc p �Q 010141 J� V.I. 07-19-9-1 PLOT PLAN to,—,.Saw.1 Seeb 'M 1. NAMFR Or STREETS OR MADS NEAREST TO On BOUNDING THE PMPRTY. 4, LOCATION OF I4OURE SEWAGE DISPOSAL SYSTEM On PRFPc SMO 2. OMUNE OF THE PROPRIFY,DINNO DIMENSIONS AND NOM"DInECTHON. EXPANSION OF SEWAGE DISPOSAL SYSTFMS. S. DIMENSIONED OMLINF6 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN MDIUB OF ONE FUMVED rIfTY R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIXS. ON Tiff PROPERTY OR ADJOINING P ROPRTY. {)ease SES �}1 S - E N(J Vie++e(r, .pA-"e o) 1 -7 L>�►i i 9 9"7 PAYMENT RFrErVFzn AUG 8 1997 SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DMS.•. F. Y DEPARTMENT USE ONLY Alplbelbn Aneenl.M BY / l 1 I/ � V.I. V J � M.. 7y" Oroul Imnztlnn PY ))) /// / O+In RmP InmwSnn PY Geln bTmnllen In.nentlno Rr / /,Al D+rn Cemmnxr JPL(7, ACCOUNTING ONLY: AIV/ FACT rE COnES FEE IMO AMOUNT"XMIT1ED CIIECXI.'CASH RECEIVED BY DATE POpEITISPLVRE REamal"UNISYS INVOICE Pub,Health Saw.-Emira.173(3196)