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APPLICATION FOR WELL! UMP PERMIT SAN JOAQUIN COUNTY PUBLICHEALTH SERVICES ENVIRONMENTAL HEALtH DNISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 466-3420 NOW-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED ICampkte In TrlpAeirul APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND OR INSTALL THE WOFK DESCMSED.THIS APPLICATKIN 18 MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS DARDS/O.FFYSAN JOAGM COUNTY F+TfBI,iC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN9 �V -o3. NQS N� CP JJf `f:Z� CITY L}._ G' I�NiV 'ARItCSIZE/AFNF OWNER'S NAME j�rLC' �� oC/ o— ADOf$SB� � (J b"-)x �/✓ I ! t•r� SNE �J (� ��yCONTRACTOR i� o :l- -I�t N4 + t G�^+ i ADDRESS S,IV c�� 16)96 -j67 0 J -S cf1f�r , P UCS G L OPHIONE! I Sue CONTRACTOR ti TI AOORE$SP.a &AX 30 12 �I LJC. TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL I.TONITOFONG WYE IF Is- ❑ OTHER ❑ IN@TAUATION ❑ WELL @Y@TEM REPAIR [3 CR08S-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL ❑New❑Rep.@ H.P. DEPTH PUMP SET Fr. FIRST WATER LEVEL. O STYPE OF PLFMPF ❑ Ow-OF-SERVICE WELL ❑ GEOPHYSICAL WELL s ❑ SDR.BOWNO g OESTRUCTFON: INTENDED ULE TYPE OF WELL CONSTRUCTION XMIFIGATIONA ry p ❑ INDUSTRIAL ❑�OyEH SOTTOM DIA.OF WELL EXCAVATION OLA.OF CONGVCTOR CASINO D r ❑ DOMESTPC1PRIVATE l.!fJMVE1.PACKMZE,L,Cfd TYPE OF CASINGISTEEUPVC V DIA,OF WELL CASING_ �� _ 0 ❑ PUSUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION It 0.1RRroATIONIAO 11OTHER GROUT SEAL INSTAL-LED HY ja GROUT BRAFID NAME E 3(MONITORING ] C/ GROUT SEAL PUMPED: Yee E3-- CONCRETE PEDESTAL BY DRILLER:❑Yee'"❑N.�� S APPROX.or", iJ1�J tacxI O CHESTER BOXAMOVE PIPE . C,( L-/ PILO W,46 )- Lt:J' /6,4V PROPOSED CON@TRUCTION/DRIunm METHOD: MUD ROTARY AIR ROTARY AUGER;�C CABLE - OTHER 3 I HMSY CERTIFY THAT 1 HAVE PREPARED TT48 APPLICATION AND THAT THE W01K WILL BE DONE RI ACCOROANCE WMM BAN JOAGUIN COUNTY ORDiNANCEB,STATE LAWS.AND RULES ANO PEOULATIONs Of THE SAN JOAO"COUHYY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CtRTIf%S THE FOLLOWING:I CUTTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED.i SMALL NOT EMPLOY PERWNB SUB.IECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.- CONTRACTOR'S HIRING OR 81,1"ONTRACTIFNH SIGNATURE CEFmFK THE FOLLOWING: 'L CERTIFY THAT!N THE ANCE OF THE WORK FOR W ICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIOMAN'•COMPfTIeATLON LAWS OF CAIJFORNIA.' THE ANT MNt7 CALL ib 'ADVANCE FOR ALL REQUIRED IRt►EOTIONi AT 120"44W4422. COMA)TE:OHAVNNG AT40WER AREA PROVIDED. Blond x �> nasi; /L'IiJr ££yy,,��_--i�� 1/"eel_ Otte '. FLOT FLAN Nrew to Go-lei Saelw 'to Iii, !ef� {��y"1�r'.., I. NAME$OF STREETS OR RDADS NEAREST O R SOUNDe a THE PROPERTY, �. LOCATION OF HOU BEVYASDISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING NB AND FNORTH DIRECTION. EXPANSION OF SEWAGE Of Al @Y@TEM@, 3. OINIERM ONED OVTLINII AND LOCATION OF ALL EXWnNQ AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FiF1Y FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIO@,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOMMG PROPERLY. :. .'......: E ' ., ..,.. .. ..... .......... .............. ...... ..... ... . DEPArenwarT u$[beer Appdeetbn Aaeaptad BY ``V 1.�r�{ � Onr -2- GrpuU I-peown 8T ]rAwA..i r-. vats—2- IL P�vlr»peetfen BILI Dole Oeoltuetlen Impaction BY Geta i i Cemmmkp: ACCOUNTING ONLY; AIDS FACT PE CODES FEE INFO AMOUNT REMITTED CHEC"MASH RECEIVED sY DATE PERMITISEAVICE REOUEST NUMBER INVOICE Aub Health Serv.-Enviro.173(11977