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*APPLICATION FOR WELLIPUMP PERM SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DP- )a1 131 1� d 1S ICompkto In Tdpikmtll APPLICATION IS HERE BY MADE TO THE CAN JOACUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AOORESSIOR/A'M# L5 la S tj • T�a -. S--k- k- CITY -' �cy--y' Jj IPARCEL SI2E/APN/ 13?•,;11!-0 3 - 1 OWNER'S NAME w(MAC.�"I�,p'L ��ICL 'DK-�R.tQ- `-^�"'OG . ADDRESS Ro• LJ9'71. /l cw tLca- CA ��ppPIONE I n CONTRACTORPReGIS 10�) ADDRESS I400 S- S'a-IQ,S'r 1CI0 � 30 P4(ONEIag7—YS/S AnJSG Clt 1 LA N ADDRESS 920 KOLL C-rif— PkLuK l�ASftf9J . qZ -7680 TYPE OF WELIJPIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL• ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CPOSSLONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑pl r&I' H.P. DEPTH PUMP 6ET_M. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ I� ❑ O�VTdF16ERNCE WELL �❑ OEORY6ICALJWyET1LL�1I � L, �'601L BORN( ^ ll 6 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTICN VATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPNC DIA.OF WELL CASING D ❑ PISUCIMUNICIPAL ❑DRIVEN DEPTH OF OROUT SEAL SPECIFICATION A ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT HEAL PIMPED: ❑Y. ❑Ne CONCRETE PEDESTAL RY DRILLER:❑Yw ON. 5 APPROX.DEPTH LOCKING CHESTER SOXISTOVE PPE 5 PROPOSED CONSTRUCTIONNW WNG METHOD: MUD NOTARY AIR ROTARY AUGER CABLE OTHER I HEe SY CERTIFY THAT I I4AW PREPARED THIS AFFMATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF T14E WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR 9U"ONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPIIC NT NST CALL 2H/OURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT LMH 4"4M23..1 COMPLETE OMWING AT LOWER AREA PROVIDED( % V'P X Jill. S�; I/`^' 1 T (-LYlG�01 f—� D.1. MOT MN SN.1.%W.I 1. NAMES OF STREETS OR ROADS NEAREST TO OR BO'NOING 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. O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED - S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FI. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. i ;n; l DEPMTMENT USE ONLY .d 2 7� APPBeabn AeeePled BY " �/ D.I. / l' Nu , GrPVl lrrtp%lbn By_ Dela p .P..Uen 0y D.rai v De.vwllen I..P«Ileo Br o.l. cemma,lR 1..1 ':j� ACCOUNTING ONLY: AIDF FACS PE CODER FEE INFO AMOUNT REMITTED CHECKI.CASH RECEIVED 1 DATE PERILITISFAVICE REQUEST NUMBER INVOICE o g +L 044{ 3 Pub.HeBUh Serv.-Enviro.173(1/97)