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1puw APPLICATION FOR WELL,IPUMP PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES : ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209)488-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICBmpIItl hr TrIphatsl APPLICATION IS HERE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE YORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN i JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9• 115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIMCION`. JOB ADDRE89A7R APN/ !•!/ '/� CITY ,PARCEL 81IE1APHN OWNER'S NAME ADDRESS >� PHONE N lflY�X3'�•+��I CONTRACTOR ADDRESS. Urso�, D .�UyCyr-��I y 13 P►IONE 2 SUBCONTRACTOR ADDRESS �H.T TYPE OF 1NELL"MPI ❑ HEW WELL ❑ REPLACEMENT WELL ❑ MOMTORINO WELL! © OTHER ❑ INSTALLATION ❑ WELL IYeTEM REPAIR ❑ CRO9I-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL S J ❑Naw❑Rapm H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ITYPE OF PUMPI SrJ ❑ OUT-OFBtiRVN:E WELL 11GEOPHYSICAL WELL! WN 8 r ❑OEBTRVCTR7N: INTENDED USETYPE OF W CONSTRUCTION SPECIFlCA IONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO ❑ OOMEBTN:IPRIVATE ❑GRAVEL PA.CKIm2E TYPE OF CASINGMTEELIPVC DIA.OF WELL CASINO O ❑ PUBUC/UUNICIPAL ❑DRIVEN DEPTH OF GROUT REAL 910 SPECIFICATION R IT NRRIGATIONIAG ❑OTHER GROUT REAL tNFTALLED BY GROUT BRAND NAME >_ ❑ MONITORING f GROUT BEAL PUMPED: ❑Yea ❑Ne CONCRETE PEDESTAL BY DRILLER:❑YM ❑N. S APPROX.DEPTH ' / LOCKING CHEmn BOXISTOVE PIPE S PpOSEO CONSTRUCTIONMOILLIMG METHOD: MUD ROTARY AM ROTAAUOER� CABLE OTHER IWRY I HENEBY CERTIFY THAT T HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REOULATION9 OF THE IAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTWIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TWO PERMIT 19 ISSUED,I SHALL NOT EMPLOY PC NO SUBJECT TO WORWAN'8 COMPWNIATION LAWB OF CALIFORNIA.' CONTRACTOR'S HKRINO OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY 714AT IV THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERB0048 IUIJECT TO WORKMAN'S COMPOISATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 NO 1!1 ADVANCS FOR/ALL REOUIRED INSPECTIONS AT 12091460-9427. COMPLETE DRAWING AT LOWER AREA PROVIDED.' Bir—k �.�O�//¢ — - _ Data i PLOT KAN Ihrx to Savel Ie.l. to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERrY. •. LOCATION OF HOUSE SEWAGE AL SY8AL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROpERrY.GrV*M DIMENSIONS AM NORTH DIRECTION. EXPANSION LOCATION F SEWAGE THINDOOPRAL SYSTEMS. 7. OIMENBIONEO OUTLINES AND LOCATION OF ALL EXI8TWO AND PROPOIEO S. LOCATION bF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY F7. STRUCTURES,VMLUOIN4 COVERED AREAS 9IK:H A$PATIOS,DRIVEWAY8,AND WALXS/ ON THE PROPERTY OR ADJOINING PROPERTY. t I -.170 03 �&s . ii... ..... -.'. . :. s $� 9 ► FEB 17 1999 .,I««AhYh#t7Ei �N tIVV1ROfVNf1►NTA OIWTY : .t If 775 mMYMdNT USE ONLY AOPB..Na,Aaaapted Br O,&k„P. „e„BT Date Pane 1r»vdeelen By Oah Derinietlen I�wveallen BY Does CmnmaMr ACCOUNTING ONLY: AIDS FACS PE CODES FEE WFO AMOUNT REMITTED CHECKI'ICAIH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBIER INVOICE 77