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APPLICATION FOR WELUPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE_S ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES T YEAR FROM DATE ISSUED (GMplttt In TrIpllEtul APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMA INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITIt SAN JOAQUIN COUNTY DEVELOPMENT TITLE,,lC'HAPTER 9-111 S.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSGOR APNI TY) -5 W f E'Cy Llt-kA �Th'�'"!-fi CITY nn1 1�?!-V �L PARCEL SIZE/APNI 835- (y OWNER'S NAME/I��l�r, -R.bLe,,,^e`•� Lc ADDRESS Ca &1V bl f (IfC+I.�� CO•/�� PHONE/ 835-p 7 Z� CONTRACTOR /YID/ A-SSGL-L 4I+J ILPi ADDRESS HIT n7i'40"4i r4LW1 "'A UC/ PHONE/S/!'ZLLI SVS CONTRACTOR 1..LN t l�lV� ADDRESS��lJOX' S I &o USS k uc►IA42LI_PHONE#P Y 3Z''t-Ld is TYPE OF WELIJPUMP. NEW WELL 11 REPLACEMENT WELL MONRORNO WELL/ a ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELLf J ❑New❑P-.k H.P. DEPTH PUMP set FT FIRST WATER LEVEL 0 R YPE OF PUMP) ❑OUTCFSERVOE WELL ❑GEOPHYSICAL WELL/ ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION{ pp A, A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONO�ll DIA.OF CONDUCTOR CASINO N 0 ElDOMESTIC/PRIVATEElRAA,, DOMESTIC/PRIVATE GRAVEL PACK/SIZE TYPE OF CASINO/STEEL VC WL-+ DIA.OF WELL CASINO Vl 0 ❑PVBLICBdUNICRAI ❑DRIVEN DEPTH OF GROUT SEAL W L SPECIFICATION SGa R ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED Sy L- `y ��•' GROUT BRAND NAME�' �yNNe� ' E RL� MONORNO GROUT SEAL PUMPED: Yr ❑Ne p CONCRETE PEDESTAL BY DRILLER:111'9 Y- S APPROX.DEPTH T'�^'- LOCKM CHESTER BOX/STOVE PIPE Al� R5 PROPOSED CONSTRUCTION/OLLINO METHOD:MUD ROTARY AIR ROTARY AUGER /��CABLE OTHER I HVEBY CERTIFY THAT I/GAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE LITH BAN JOAQUIN COUNTY OGENHANCES,STATE LAWS,AND RULES AND REGULATION 9 OF THE BAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT t6 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUB-CONTRACTMO SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FON WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 NOUNS IN A13VAANCI FOR ALL REOUMFD INSPECTIONS AT I2091400 122,COMPLETE DRAWING AT LOWER AREA PROVIDED./Ds SIVrdX i- /MAA 1_-_::US22HIS TJThl- RA,&ALa AJN G _ 0.t. PLOT MAN"—to S.1-1 •Me I.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,OIVM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE OIBMSAL SYSTEMS. 2.DOANWONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED t.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STNUCTUIRES,WCLUDINO COVE19IED AREAS SLICK AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINM PROPERTY. 1 CANOPY II a s4c. UILDING ' _ I ansa• sn+l ��ww.rmcse et CANOPY ' BUILDING i } avoaesro uamcn.c'.x,.rac.rw ' v�n ur¢ I�I scalE BO EE FAYETTE MANUFACTURING CORP. GENERALIZED M1Mi/ 7675 WEST ELEVENTH STREET SITE PLAN l v 2 TRACY,CALIFORNIA , �,.`j QA �/)' btIAR(sww.P WB 3r.�Y (Apjliee�len-A—o dBY YAA U/l A, /Orovl Irnpeetbn Br O.t. PunP IrpP.aOen Sy OH. '(De.11lcllen IM Ilan BY 1�1/� / ' /� (�V ///�� •//� nD.t. MUFS' 1/!�• lCommpN.: -� VI+� YY - ACCOUNTING ONLY: I AIDF FACT PE CODES FEE INFO AMOUNT REMITTED CHECKI/CASH RECEIVED■Y DATE PERMIT/SEANCE REQUEST NUMBER INVOICE Pub Health Serv.-Enviro.173(1/97)