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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR TROM DATE ISSUED <br /> (CBmpNLE IR TripReEul <br /> APPLICATION 19 HIME BY MADE TO THE SAN JOADUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.7I119 APPLICATION 18 MADE IN COMPLIANCE WITN SAN <br /> MAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS Of SAN JOAQUIN COUNTY PLIBLIICC 14E(ALLTH BERVICEB,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADDAFSSMR A/M#'-DI/AR(_Y JARI(a14Y ROAI) E> rFti51aJ CITY p ILA HR—OP PARCEL 9IZEIAPN/ <br /> OWNER'S NAME 4EAj/l���Q�1 x0.1 111C11�QClClYIWIJT AGGRESS 1�ZO ViCk VIµ�yrryjl S/an CltYIIG✓1'It: PMNE.7+H 587�'3Y0 <br /> CONTRACTORlL /T7SC)C,IM1Q.tLAwS }Y1 C -. ADDIESB IZLOG(1linlT�tC(i�( 'yGfSID(�ljIC1 J��IJ.�1 {'NONE/LI.YT S7`I'22i2�/ <br /> SUBCONTRACTOR F15h L-A')1 ron(Ae. taJ ADDRESS 3ql 54 7e_/T 5 1�{y-c-GO�IrM/1_Mx e,93 SLS PHONE/ZOL 7L <br /> TYPE OF WELL/R1MP. ❑ NEW WELL ❑ MP ACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO88-CONNECT REPAIR ❑ VAMA EXTRACTION WELL/ ✓ <br /> ❑N.w❑R.P.b H.P. DEPTH PUMP BFT FT. FIRST WATER LEVEL O <br /> (TYPE Of PUMP) {/ <br /> ❑ OVT-0E-BERVIOE WELL ❑ OEOPHY6ICAL WELL/ X 6011 BORING 14 T B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION LNI DIA.OF CONDUCTOR CASINO N/I''{ O <br /> ❑ DOMESTMC VATS ❑GRAVEL PACK/BtZE TYPE OF CABINOI6TEEL/PVC NI/{ DIA.OFWELLCASINO NIR O <br /> ❑ PUBM MUMMWAL ❑DRIVEN DEPTH OF GROUT SEAL 114 ' SPECIFICATION N 64 R <br /> ❑ IMOAMN/AG ❑OTHER GROUT SEAL INSTALLED BY ApR <br /> AAA GROW BRAND NAME ppWl E <br /> ❑ MOMTOMM GROUT SEAL PIMPED: ❑Yr lame CONCRETE PEDESTAL BV DRILLER'❑Y. N. 5 <br /> M <br /> APDX,DEPTH ILf 6Pe.IL LOCKING CHESTER ROXISTOVE PPE 11 5 <br /> MOMSM CONSTRUCTIONI LUNO METMO: MUD ADTARY AIR ROTARY AUGER CABLE OTHER PVZYI <br /> I HMNY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WIU.BE DONE m ACCORDANCE WITH BAN JOAUUIN COUNTY ORDINANCES,STATE LAWS,AND RULEB AND <br /> REGULATIONS OF THE BAN JOAQ1114 COUNTY. HOME OWNTR OR LICENSED.AGENT'S SIONATUM CERTEIES THE FOLLOWING:'1 CFRTIFV THAT W THE PEWORMANCE Of THE WOW FOR WHICH <br /> TMB PERMIT 18 ISSUED,00/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALROIMA.- CONTRACTOR'S HIRING OR BUB-CONTMCTING SIONATUM CEMIFIEB <br /> THE FOLLOWING: -I CERTIFY THAT m 711E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY PEMONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' TILE APPUCAW MUST CALL 24 HON/RN ADVANCE FOR ALL MOUNTED INSPECTIONS AT IMP 440- n. COMPLETE DRAWING AT LOWER AREA PROVDEO. <br /> swe x _Nn'YV7<�n pe __7111. -RftL4" lel Q444L cM DN. 3/30198 <br /> PLOT PAN Ib.w 1e%W.1%.I.144 54-uIN l <br /> 1. NAMES OF STREFTB OR ROADS WAREST TO OR BOUNDING THE F IOMM. IL ( .. LOCATION OF MUSE SEWAGE OHIMBAL BYSTEM OR MOMSED <br /> 2. OUTLINE OF THE PROPERTY,ONINU DIMENSIONS AND NORTH DIRECTION, I ZO EXPANSION OF BEWAOE DHIMBAL SYSTEMS. <br /> 2. DIMENSIONED OWUNfS AND LOCATION OF ALL EXISTING ANO PFIOMSEO E. LOCATION OF WELLS FFN N MONS OF ONE HUNDRED FIFTY R. <br /> STRUCTURES,M;LUDINO COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,ANO WALKS. ON THE PROPERTY OR ADJOINBO PROPERTY. <br /> STOCKPILED SOIL I� <br /> CURB 1,- <br /> z • <br /> D'ARCY PARKWAY < UNSURFACED AREA 0 <br /> a TEST PITS <br /> 0 0 <br /> o-------------------- <br /> EX AARVA�TION <br /> • <br /> I <br /> I <br /> UNSURFACED AREA , <br /> DErrAwTME T w[any <br /> A,Aeot�A�tol By Demo <br /> GroU Impeelbn BY �„eJ w oHs BY HF <br /> On.V1c11en Irnpeelbn BY <br /> ACCOONTING ONLY: AID/ FAC/ <br /> PE CODES FEE IWO AWVNT REMITTED ASN RECDVEOSY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />