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i' APPLICATION FOR WELL/PUMP PERMIT E SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 458-3420 L t MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROG DATE ISSUED M mplet@ 111 TripRat@I !f APPLICATION IS HERE SY MAIN TO THE SAN JOAOUIN COUNTY FOR A FERMI,TO CONSTRUCT ANOMS INSTALL TRSE WORK OESCRIBEO-TIB#AFM CATION IS MADE IN COMPLIANCE WIT}I SAN JOAUUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11 1S.3 AND THE STANOARDB OF BAN JOAWN COUNTY PUBLIC HEALTH SERVICER.ENVmONMENTAL HEALTH DIVISION. 11 JOS ADOMSMOR APNl135D Bxa lac�dg n Ave. CITY � - --- --PARCEL MZUAPNF a' ` �1 ' . OWNER'S NAME 1 cf � AOUPEOR P.O. �{ �1 G� R�IQNE f `W CONTRACTOR AOOF X@J 5 1 VistaJC/=4 wwNE.707 D4=281 :I BUB CONTRACTOR ADOREBB ' LIC/ PHONE f TYPE OF WELt/WMP. NEW WELL ❑ REPI/10EMENT WELL iJ MONITORING WELL F ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ;i ❑ VAPOR EXTRACTION WELL t J 13Nw ❑Rmo h H.P. DEPTH PUMP SET FT. I FIRST WATER LEVEL. O t>YPE OF RlMy ❑ DVT-OF-evwxE WELL _ ❑ AEOPHY=cA&Y m I EF ❑ $OIL somma 8 ❑DESTRUCTION 'r INTF]IDEO USE TYPE OF WELL, - CONSTRUCTION SPECIFICATIONSI' A ❑ INDUSTMAL {{❑��OPEN BOTTOM DIA.OF WELL EXCAVATION 8 I11 � DIA.OF CONDUCTOR CASI^N�rO O ❑ DOMEBTICIPWVATIE py.l GRAVEL PACKIBIZE rn � TYPE OF CAeOISTEELRVCAII PSRL: If OIA.OF WELL CA61HO G O ❑ PVNX/UUN1CIPAL ❑DRIVEN DEPTH OF aROUT SEM 401 _. 8PECtMATION R ❑ IRS@GATIONIAG ❑OTHER aROUT SEM S16TAuim sY TCHLIIBRAND NAME k GROUT BRANAME ]'get C1nI't E MONITORING G/IDUT SEAL PI/LIIFED:Ely. ❑Ne .l CONCRETE PEDESTAL BY DRILLER:❑Y. CIN. S AF7ROX.DEPTH LOCRRGG CHESTER BORIS'TOVE FNS S PROPOffD CON@TRIUCTIONIORLUNO METHOD: MUD ROTARY MR ROTARY AUGER X CABLE OTHER I� i 1 HEREBY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RU1E8 AND MOULATIONS OF THE SAN JOAQUIN COVNTY. HOME OWNER OR LICENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWRIO:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSON@ SUBJECT TO WOM MAN'S COMPENSATION LAWS OF CALIFOFM/L- CONTRACTOR'S HIRING OR SUBCONTRACTWO SIGNATURE CERTIFIES THE FOLLOWING: 'I.CETHAT PERFORMANCE OF THE WOFK FOR WINCH THIS PERMIT IS 188UEO.I SHALL,EMPLOY PERSONS SUBJECT TO INOW MAWS COMPEfgATROR LAWS OF CALIFOM . APPU AM C FOR ALL REO1ARM IN@PILTIONB AT t"I"40@i422. COMPLETE ORAVAM AT COWER AREA PR�O - Slor.ed X Ir �T111e It Dno I' r if PLOT FLAN Ww. to Saelel 8e.le .'s 1 1. NAMES OF STREET@ OR ROADS NEAREST TO OR BOUNDMG THE PROPERTY. E} <. LOCATION OF HOUSE 8EWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.OGVNIO DIMENSIONS AND NORTH OMECTION. EXPANSION OF SEWAGE 00 SAL SYSTEMS. ]. DNAENSIDNED OUTLME@ AND LOCATION OF ALL MOTING AND PROPOSED `.� s. LOCATION OF wELLs WITHAL RADIUS OF ONE HUNDRED FIFTY FT. BtRLIcnmEs,aCLUDRNO COVERED ARMs SUCH At PATIOS,DRIVEWAYS.AND INAUts. I OH THE PROPERTY OR ADJOINING PROPERTY. FI?r w kplat did 3:31/9 ....... - 1 ..r m j ...... "'F I p IF .................... Ii ........... ...... ................... ......... OEPMTMMT USE ONLY l /C Dne AppBanfen AaoepNd BY, �Jl,�.4 aAil rL7//1� Mee— —'-- --•- Oral Il memckm OW 1 11._.1 nn_r"0-f- One f Wnp hvpeatNn Sy r Dete I' h O"Rr tlen Irnpeelbn BY 11 Date �i Cmrm+erMe: � ' II a ACCOUNTING ONLY: AIDS FACE 4 PE CODES PEE INFO AMOUNT REMITTED CHECIWICASH RECEP/w @Y DATE II P9eMITINE RVICE REQU UT NUMBER INVOICE Ep e� Pub Health Serv.-cnviro.173(1(97) I