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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SwP4di� DlrNED ELj •3Q ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 1 (209)468-3420 N0N•REFUNDARkE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (Compl►t►In TFIpLW@) H".J,'7 APNRICATION to HERE BY MADE TO THE BAN JOAQUIN COUNTY FON A PERMIT TO CONSTRUCT ANGOR INSTALL THE WORK DESCRIBED.TRIS APPLLION Is MADE IN COMPLIANCE WrTH BAN JOAOUN COUNTY DEVELOPMENT T�.CHAPte"9---111 F.7 AND THE SIANOARDS OF BAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, JOSADORI:SWORN111 1008 7Vhit.f. r.N CITY Stockton ��I� PAFCELSIzE/AEN. OWNFR'S NAME_ Gorcion rraVPl l P ADDRESS Sgame PHONE/9 31—0222 COMPACTOR Moormam Water SVs mG ALIORESs 21 20 Wi 1 r`nx Road IJc/46881 6 PHONE► ��1 n PUB CONTRACTOR AD—ESB IY/ RHONE TYPE OF WEWPVMP• ❑NEW WELL ❑�REPLACEMENT WELL ❑MOHOORIPIG%ELL/ ❑OTHER �7� ❑INBF TN.LATION E kmLL SYSTEM REPAIR ❑CROSSCONNECT REPAIR 13 VAPOR EXTINCTION WELL E J Sub ❑N—0RN,.1. H.P._4� DEPTH PRIMP SET FT. HROT WATER LEVEL��I (TYPE OF PIMP ❑—V F-SERVICE WELL ❑DEORHYBICAI.WELL/ ❑ SOIL BORING S ❑DESTOPCTION: NiENOEO UK YPE O ELL CONSTRtDCTON 1WEGFIC ION A ❑INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION CIA_OF CONDUCTOR CASINO D b ❑OOMEeTIC?PWVATE ❑ORAVR PACKNPIZE TYTF OF CASINGMTEEL.FVC VIA.OF WFZL CASINO O ❑m.LH:MUNICIPAL ❑onvTN DEPTH OF GROUT SEAL SPECIFICATIVN R ❑IRRIOATIOMAO ❑OTITER GROUT SEAL INSTALLED BY GROUT BRAND RAMS E ❑MONITORING GROUT SEM PUMPED:❑Yr ❑N. CONCME PEOEBTAL BY ORFLJ FR:❑Y.. ❑Ne S APPROX.DMH LOCKING CHESTER eOXIeTOVE RPE S PROPOSED CONSTTILPCTIONIDRIWNO METHOD: MUD ROTARY AIR ROTARY AUGM CABL2 OTHER I HFWBY CERTIFY THAT I IIAVE PREPARED RNIB APPLICATION AND THAT 7HE WON(WRL RE DONE IN ACCORDANCE VMH BAN JOAOUIN COUNTY ORDINANCES,"ATE LAWS.AND RULES AND RMULATIONB OF THE BAN JOAOIRN COUNTY.HOME OWNER OR LICENSED AGENT'S SIONATVRE CERTIFIES THE FO LIOWINO;•I CERTIFY THAT N THE PEWORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 16 MO.B RHAU NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA'CONTRACTOR'S HIRING OR SUBCONTRACTING BIONATURE CERTInto THE FOLLOWINO: '1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WINCH THISPERMVI IB ISSUED.I SHAU EMPLOY PERSONS SUBJECT TO WORIOURAN'S COMP"SAT10H LAWS OF CALIFORNIA.• Ui ARUCAM MUST CALL 24 HOURS N ADVANCE FOR ALL RiNIWIm INSRDT_IONNS J AT n"I 4N 422.COMPLETE DRAWING AT LOWER AREA PROVIDED. at,-X �"L�4L�Z�i�2 �""�/N }I� TRN—` ROT MAN III....N S o.I 11-1. H. O 1.NAMES OF BTREFBB OR ROADS NEAREST TO OR SOUNDING THE MIOPEIOI', 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYRREM OR POMAED 2.OUTLINE OF THE PROPERTY,OMNO DIMENSIONS AND NORTH DIRECTION, EXPANMON OF SEWAGE DISPOSAL RYSTEMe. I ].OWENSIONED OVTURFS AND tOCATIVN OF ALL EXISTING AND FIOPOSFO e.LOCATION OF WFLLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. L"YVL STRICTURES.NCLUDUFO COVMEO AREAS SUCH M PATIOS.DRIVEWAYS•AND WALK.. ON THE PROPERTY OR ADJOINING PROPERTY 05LL i s y 5� 'A TC.....:.: ,�...: .... , e'er rn�u h .v�.o F work b in ��'r�a..Mthn S. L . b e° R1ett r bli, PAYNdEi�[g :. . ..;. .......RECELwED . ... JUL 2 5 1997 � 5`A)'V'JaA�tUIN'CfiUNR' - VSKI?l . . :..... ..: .. _... '.._. ... `ENV PUBLIC HEALTH SEFIIf - ... IRQNMENT4L HEALTH fx ` DEPARTMIFNT VSE ONLY AAP11o.N.n Aempl.A By DsIn..Hl.n InvMl.n By 0.i. I c.mm.M.: Yk.%i9Itf��icLSZ�L�;r��T-v 1�itz�,;�%�v-`.'��-i�-�• .�%1��.��.�s .�� I AceolNnRro orMLr: nlD► FACS FE CODES FQ INTO AMOUNT REMITTED MASH REC6Vm BY DATE PHPIIITISSRVICE REOUEST NUMBER INVOICE 24 04(0 R o { Pub.Reetth Serv.-Enviro.179(1/97) •w i