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t t APPLICATION FOR WELLIPUMP PERMIT _ $SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI , , ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, %x EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICBmple0i In TrlpBaalel APPLICATION IS HEM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE`MIH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1/11115,3 AND THE RT.ANDAFGS OF SAN JOAOUIN COUNTY PUBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH OMINOM. / JOB ADDRESSwR AM. 1,l 31 1�rl��LeLI�1 c /1yt CITf 6TOCA 1-0)11/�0� PARCEL S12EIAPNI Q (7 OWNER'S NAME Vdit I/`Td �O ADORE BIJ kY YOA3IV. 0 A�yQ� MoNE+M-6 Tt-6668 CONTRACTOR l .��I�V�IpY-05 ./NLI(� ADDRESS p�,O.OD/- 2 1��VF!CNY,MAI mom, 707-93.f-44.515 SUBCONTRACTOR VLLJ7��)I'1 .`A ADORERS /�O W'C Q 7�/ 'obi—PIwNE/�i10-313-SSAO TYPE OF WEIIMIMP. 03❑ INSTALLATION ❑ WELL SYSTEM RE AP IR ❑ CMS"ONN WELL REPAIR ❑ OTHER ❑ VAPOR EXTRACTION WELL/ ✓ ❑H.11 Peva, H,p_ DEPTH PIMP SET----FT. FIRST WATER LEVEL O TYPE OF P MP1 UT ❑ O -OFBERVICE WELL ❑ GEOPIV6ICAL WELL SOIL BORING ❑DERLRUCTION: TYPEOFWELL CONSTRUCTION SPECIFICATION& A INTENDED USE p ❑ INDUSTRIAL [I OPEN BORON DIA.OF WELL EXCAVATION o II DIA.OF CONDUCTOR CASINO q O ❑ WMESTICMUVATE ®GRAVEL PACBIm2E ,i�o.(tA{ TYPE OF CASINO/STFELNA VC QVC- DIA.OF WELL CASINO ll D ❑ MBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL I SPECIFICATION 54A NO R p❑1 IPRIC.ATIONIAO ❑OTHER GROUT SEAL INSTALLED By ��LL UTI164 GROUT BRAND NAME E La MONITORING GROUT SEAL PIMPFO: ❑Yee [IN. CONCRETE PEDESTAL SY OA1MFR:®Y" ❑Ne 5 APPROX.DEPTH LOCKING CHESTER BO%/STOVE PPE S PROPOSED COMaT1UCTOMIDRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER ✓ CABLE OTHER I HEREBY CERTIFY THAT I IIAVE P,EPAWO THIS APPLICATION AND THAT THE WOR(WILL BE CONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OW14Ei1 OR LICENSED AGENT'S SIGNATURE CEPTIFIEG THE FOLLOWING:'I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH TIROS PERMR IS ISSUED,I SIRALL HOT EMPLOY PERSONS SUBJECT TO WOMMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S MINING OR RUB-0ONTMCTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORWAM'S COMPENSAT I R LAWS OF CALIFORNIA.- FORNIA.' THE AVCANT MUST CALL 24 MMS IN ADVANCE FOR ALL REGIMFp IN.PepTloMa L � ETE d1AWIN0 AT LOWER OAMA '70-J411 Th'. � FA Blyrgd% POT PLAN[0,—le Seelel BeNe 'le 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE AL SYSTEMS- 2 SS- OR PROPOSED 2. OMLINE OF THE PPgPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE THIN RAI S O FON 3. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS "JON MONS OF ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ApJ01NN0 PROPERTY. pAMTMFMT USE ONLY ApeFeellnn AeeeeleH BY UeR �- I ha GPM Imemlbn Br Drls Pvnv Imvmllen By Dely OMingllen Imneellen By DMA Gemn,m,.: M�^� �o�l boW�l✓�,�5 �, ACCOUNTING ONLY: AID$ FACE PE COOEa FEE INFO AMOUNT RETIRED CNECX/ICASH MCOVEO BY DATE PEFEWTI&EIVICE MODEST NUMBER INVOICE Pub.Health Se".-Enviro.173(3196)