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YME�� ' APPLICATION FOR WELLYUMP PERM 7 PA ��Er; S� OAOUIN COUNTY PUBLIC HEALTH SL .ICES �`� `f-S Z 1. G z R� 'o ENVIRONMENTAL HEALTH DIVISION 00V 2 200 304 EAST WEBER AVENUE, STOCKTON, CA 95202 . (209)468-3420 SAN 30A(aUIN GOUNT NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P,�U�ft��UpC H[ALTt1N SAUS p 1ER4 p VISION (CompNu In Triplicalel AM`LIC APyy11,��,VVlIhti»�"riI B;i,d/ q6 THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DEECRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN, COUNIY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERV)CES,ENVIRONMENTAL HEALTH DIVISION. / JOB AODRESS/on APNN,I/J'- �f' I //j J f -( /�/�)T/ - CITY -/�f-T/'//�'-� PARCEL SIZELAPN/ /f �- OWrJER'S NAME / (`r��At-"i �J��n-��/�J ADDRESS RHONE/ c )1 IeNT RActorEf 7e i "L/� 41i'01-*- ( --,f 3L i L, /� L CP Is.: I/ � �S AbDnEe6 �Z jZ) S�r 6C1 PHONE I, / FVB CONTRACTOR Ic—L-":! /N 17-•j, L I, rADDRESS Z� 7 L� �- /-��I7 77 /t-ACR PHONE I TYPE OF WELLJPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL/ 3 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR `(I I• "(,T J ❑ VAPOR EXTRACTION WELL/ J ❑New 11Repair H.P. DEPTH rump SET FT. ( / / FIRST WATER LEVEL O N VIE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL✓r *BOIL BORING q ❑DESTRUCTION: HNTENbED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , t A ❑ INDUSTBIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION -- DIA.OF CONDUCTOR CASINOC'- p ❑ DOMESIIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEF. DIA.OF WELL CASINO 0 ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GnOUT SEAL SPECIFICATION F ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING �-7 1 GROUT SEAL RTMrfD! ❑Yea [IN. \/ CONCRETE PEDESTAL SY DRILLER:❑Y« ❑No S APPROX.DEPTH (-�� LOCKING CHESTER BOX/STOVE RPE / 1F S PROPOSED CONSTRUCTION/DPoLUNO METHOD: MUD ROTAnV AIR ROTARY AUGER CABLE OTHER 1 HEREBY 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 REGULATIONS OF THE FAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOA WIHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PER80N8 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING On BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWINO: '1 CERTIFY�- A RF�CE OF THE WORK FOR WHICH THIS PERMIT I8 ISSUED,I SHALL EMPLOY PEnFONB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE AP CANT1 IN ADVANCE FOR ALL REQUIRED INiPEC 110N8 AT(2091494-3423. COMPLETE DRAWING AT LOWER AREA PItO VID _/J� �1� l//gypBlared X / Tllle /r/ ��- r- %•l h/t��y c_ Dae / /� 0 PLOT MN IOrew to Sealel Scala to 1. NAMES OF STREETS On nOADS N AREST TO OR BOUNDING THE PROPERTY. {. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOGED 2. OUTLINE OF THE PROPFITTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPAP48ION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE IHUNDnED FIFTY F-T. \ , GTRUCTVnEB,INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY On ADJOINING PROPERTY. �1 .. .... _ - :. - � ! �•J LCF 7' ..i .i....; .i. .. ;....: .... .. .. .... .. ..... i .... i......: .. i. .. .. .. .. .. _ .. .. .. .................. . ....... K .. r�r r�.rL >. : . ... ...... I� ... .�o r S ..:....:.. . ... ....... .. .:.... ....;.... ..... . . ... .. :. :. '.. DEPARTMENT USE ONLY Appilcalen Aceevted By Data ' / Ar Orord Imvecllee DY Dae// 3 P-0I-Pectlon BY Ove 0-1,—ti—Impaction Y Dae r Cemment.� �� v'L_ O et J/•2"2noo /dSc'R�A1 �o3aa7'� -lZ s9vd z �E�cK� ti -�' AfTg ACCOUNTING ONLY: AIDE FACT 7b saR Np .7 Q4"IA7 PE CODES FEE INFO AMOUNT REMITTED CHECK/I �LSII nECEVED BY DATE PERMITISETRVICE REQUEST NUMBER INVOICE 'J;.o BOG' /0 1 L 11 2 1/C, L -- Pub.Health Serv.-Enviro.173(1/97)