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APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES n ENVIRONMENTAL HEALTH DIVISION FILE O P Y 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NOR-REFU11DASLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICempkfs In TTip"astal APPLICATION 18 IIERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIFOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WTTFI SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS Of SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSIOR APNF 2 2 5 6 3 S o . 7th St . CITY !B��a n t a PARCEL SIZFJAPNI Q OWNER'S NAME Banta Inn ADDREBB P . O . B x .34 Banta , :a . PHONE A 3 5- 13 1 1 CONTRACTOR Freitas Electric , Inc . AbOREeI ' 0 . Bx 16 BaynJ,�ta , 53962 PHONE 1835-28 T4 RUB CONTRACTOR ADDRESS' '^` LIC/ PHONE• _TYPE OF WELIJW,Mp.. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER 1' S U b ❑ INSTALLATION ❑ WELL BYSTEM REPAIR ❑ CROSS-CONNECT REPAIR © VAPOR EXTRACTION WELL I J ❑Naw❑Rapelr H.P- _ DEPTH PUMP SET 6 0 FT, flRSt WATER LEVEL 1 2 O ITYPE OF PUMP' Replacement 7(-'-SEFI- ❑ DUT•OF-SERVICE WELL ❑ GEOPHYSICAL WELL L ❑ 801E BORING g pI ❑bESTRUCTION: ` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIOND A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p I ❑ DOMESTIC/MVATE ❑GRAVEL PACKIBIZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CASINO p PUBUC/MUNICtPAL ❑DRIVEN DEPTH OF[TROUT SEAL SPECIFICATION 8 k 'IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY OROUT BRAND NAME E 1 ❑ MONITORING GROUT SEAL PUMPED, ❑Yw [IN. CONCRETE PEbESTAI SY DRILLER:❑Yec ON. S a APPROX.OEPYH 1 4 6 LOCKING CHESTER BOXISTOVE PIPE s PROPOSED CO."11"UCTION1DfpWNO METHOD: MUb ROTARY AIR ROTARY AUGER CABLE OTHER II HMOY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND #I REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S BIONATURE CERTIFIER THE FOLLOWMG;'1 CERTIFY THAT 1N THE PERFORMANCE OF THE WOW FOR WHICH 1" r THIS PERMIT IS ISSUED,I B14ALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES N I THE FOLLOVAM: .I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 48 IBRUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF I CALIFORNIA.' THE APPUC MUST CALL 24 HOURS IN ADVANCE FOR ALL REOU ED I SPICTIONS AT 120014041-3422, COMPLETE DRAWING AT LOWER AREA PROVIDED. 4. Signed X f� ^, Title .. Date 4/1- / U PLOT PIAN IDraW to 80a10 Scale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4, LOCATION OF HOUSE SEWAGE DEPOSAL SYSTEM OR PROPOeEb G 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTINO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. BTRUCTUREB.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, I� { ... -.-- _ G : - -- r.. ... ... Al : C ; PAYMENT Pr _:1VFr1' SAN JOAQUIN CUUt1TY' PUBLIC HEALTH SERVICES 1 DEPARTMENT USE ONLY f ApPFlaellon Accepted BY LA .......... Oreut Ir Pecrton BY ■la Puma Inspactla..By --� -Dole O Dc.lruellen I--Peden 9Y Data i CammaNe: ACCOUNTING ONLY: AIDR FACS PE CODES FEE INFO AMOUNT REMITTED CHECK ASH RECEIVED BY DATE PBWRITISERVICE REQUEST NUMBER INVOICE 01570 µao�q 1 �laa r198 . �6� Pub Health Serv.-EnvirD.173(1197)