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APPLICATION FOR WELLIPUM12 PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 JUL 0 9 2001 (209) 468-3420 NON-REFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED KLEO&M- (CompletE In TrlpReaE) APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WON(DESCRIBED.T109 APPLICATION 18 MADE IN COMPLIANCE WITII BAN JOAQUIN COUNTY pEVELOP{MEMnTRLE,CHAPTER ,T•0-1116.0 A�N17pAT�HE BrANOA{�{�{'{[ggq))),8'1\p{F BAN AAOUIN COUNF(Y PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTk0M8N.',, eJOB AOOREBBARAyPH,E EB•[�}� lV. 4(1111L1 11\K�( 1'(..1 CITY�IA PARCEL BIZE/APPr `OWNER'S NAME 1 'TZ f. l EILk 'YteMe < �AGGRESS / 1 IIF I ♦ pp ' COMMCTOR_E1L'AS_AS C�CIIDI� �A (` ADORE88� 7TC ry UCI TOE Am CONTRACTOR ADDnEByf30]...,,UFFf;EEEC'LIY'IMI IQ�r�f�/F.' QS Q�J Lx:E �I F�IIi:I S_Ld�12 TYPE OF WELI/PUMP• yJI�W WELL ❑ REPLACEMENT WELL JCIIgOMORINO WELL I-ys�r�rel L 1 ❑ OTHER ' /❑ WSTALLATION ❑ WELL SYSTEM REPAIR /❑ Cros"ONNECT REPAIR / ❑ VAPOR EXTRACTION WELL P RYFE OF RUMPI ❑N. 0Aso.1, H.P. DEPTH RUMP SET FT- FIRST WATER LEVEL O ❑ OUR-0F-SERVICE WELL ❑ GEOPHYSICAL WELL E- ❑ BOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF W CONSTRUCTION SPECIFICATIONS ,1 A A IJ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I' DIA.OF CONDUCTOR CASIN.O�f N Ar 0 ' ❑ DOMESTOA'RIVATE ❑GRAVEL PACK/BRE�U_ TYPE OF CASINGMTEEL/PVC DIA.OF WELL CAS/IIN'�G w2 D 11 RURU /M CUNICIPAL ❑DRIVEN of""OF GROUT BEAL S SPECIFICATION X4Syn A am,❑ IRRIGATION/Ali ❑OTHER ORDUT BEAL INSTALLED BY AJ GROW BRAND NAME—UE L ' \�MONRONNO /J GROUT BEAL PUMPED: ❑Yr ❑Ne CONCRETE PEDESTAL BY ONLLER:❑Y.. ❑I% S Amex.DEPTH 2 Or LOCXMO CHESTER ROXMOVT RPE S PROPOSED CONSTRUICtION/DRLUN I METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER ' I HERERY CERTIFY THAT I IIAW PREPARED THIS APPLUCATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REmMTIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIONATUAn CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB IB IBI/ALL TEM OY PERSONS"ACT TO WORKMAN'S COMPENSATION LAWS OF CAUFOMIA.' COFITMCTOR'S HIRING On AVBCONTRACTm081ONATUM CERTIFIES THE FOLLOWING: TIF=T AT IN IE PERFORMANCE OF THE WORK FOR WHICH THIS PERAGT IS ISSUED,1 MALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T A VST ALL 24 IOIINS m ADVANCE FOR ALL REQUMEO M TONS AT 120191 4094M22. COMPETE DRAWING AT LOWER AREA rP�NO OE . ' Bleaedx no. / OIC`// (TfltU�r/97: Dae t v POT PAN(IN .,le Saw.)%.I. ..-1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PlOrERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PropoeM ' t. OUTLINE OF THE PROPERTY,GIVING MAMBIONB AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM@. a. DIMENSIONFO OUTLINES AND LOCATION OF ALL ERISTMG AND PROPOSED S. LOCATION OF WELLS WITHIN MOOS OF ONE HUNDRED FIFTYFT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY On AOJmMM PROPERTY. ... .... .e. P P PUBLIC HEALTH SERVICES° ` q SAN JOAQUIN COUNTY "0W HARLIN KNOLL, R.E.H.S. ' Senior Registered Environmental Health Specialist Environmental Health Division >...... ' (209) 468-3442 304 E. Weber Avenue k - FAX (209) 468-3433 3rd Floor .< �,.,,.,- .•,... „ Ernail:HKnGII@phs.hs.cosan-joaquin.ca.us Stockton, CA 95202 ". , �- 1 F S Ad.., ' AmftiI ll,O Aeeeeled By �c'f ` ` ()A'(/A"�.,.� ( DEPARTMENT USE ONLY Orae)hnpeallee BY Das Pune Inro.aBen RY D.b ' De.1G.:nea lmpeeRlm Br ea. Cemmenl.: ��D.AAnf',A/L/4,-I.fA 6'LL w S 1 ' ' ACCOUNTING ONLY: AIDE FACE PE QODEs FEE INFO AMOUNT REMITTED C CKE/CASH RECEIVED SY DATE PFFWRT/SERVICE REQUEST NURIBER INVOICE 17 Pub.Health Sew.-Enviro.173(1/97) f 1