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0 APPLICATION FOR WELLIPUMP PERMIT ' AN JOAQUIN COUNTY PUBLIC HEALTH SERVIC ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 1209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICompku In Trlplkotal APPLICATION 16 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED.THIS APPLICAMN 16 MADE IN COMPLIANCE"it SAN JOAQUIN COUNTY DEVELOPMENT TRIS,CHAPTER 9-1115.3 AND TIIE STANDARDS OF BAN JOAQUIN COUNTY LPU�BLIC•1TTH�EEALTH SERVICES,ENVIRONMENTAL HEALTH DIVII'SRI,ON. JOB ADDRESSMR AN# ioLI(((��LS VLLu,�,L- R(v,��. UF_ LL;KOj(Y Ce,kf) CITY "` PARCEL SIZVAPl1 [�� OWNER'S NAME T,L'O6 ✓y^"`6 "a C/� ADDRESS Iq� �D�115},I� ;EP,F.I I�1hiGA PHONE,I(Sta 1a�✓o0 Bca,aslnow,$11L Qrojef. (<1unoyefl�.e,��wFr:KMe,•AO F eE-- RISME I cernRAe*ew L��.FAT SUBCONTRACTORIJ-"� ADDRESS IJ� ITM�W•,I 1"I/�Y{ " HCFti�-S51b5- PHONES 10)313-3.800 TYPE OF WELVPUMPI ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER- 0 THER-❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J 11 N. N.P. DEPTH NMP SET_FT. FIRST WATER LEVEL O (TYPE OF MMPI �y P �.} CyF�❑�OVrT,-0�R6ERVICE WELL ❑ OEONV6ICAL WELL I ❑ 601E 00RIN0 B I.IDESTRUCTION: ��M�e+ `0('� &_ �`-"' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONE A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOME9TIC"IVATE ❑GRAVEL PACKISIZE TYPE OF CASINGMTEEL/ C DIA.OF WELL CASINO D ❑ NBLICMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROVE SEAL NMPED' Ely. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Vs ❑Ne S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE _ (T S PROPOSED CONSTRUCTIONIDIOWNG METHOD: MUD VOTARY AIR ROTARY AUGER CABLE OTHER (_ I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO REGULATIONS OF THE SAN JOADUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'1 CERTIFY THAT IN THE PERFORMANCE OF TIIE WORK FOR WHICH Tolle PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA:'/F�1/E,,�A. / N VET CALL P IIOIBIE I�M ADVANCE FOR ALL REOURIED INSPECTIONS AT 1201114NJA2E. COMPLETE DRAWING AT LOWER AREA PROVIDED. elor,.a x C/Y '^� QS Q 7 YOL �' "udnwndb�TlD. '_.1pv �pJA��on11S``//�.nA f o.le 1)-ly- 11D PLOT PAN 0.le SeYe)Sn.le I 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. I. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PEDPO6ED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY On AO OI INO Orno ... II ` W100 6® MW10 ® CPT-100 1 MW101 2 ® CH o5 MWII ®5 4 3 C -4 1 ® \7 CH Prop��a Chevron CHMW-3 Gpc bor% \Gas Station `12 MW3 11 \ QPCINC Pv� �- CHMW-7 CHMW-6 13 0 150 FEET Station 1 1 �/�/� ,� Iy�I /�///�/ DEPARTMENT USE ONLY APPII.HIen A..Wlm aY I . `w" 1 IIAL6_ / G,eul ImP..11en By �� ow. P p Imo«ben BE D.t. Dalrlcllen ImOec,lon By O.R. Gemmer,l.� I� U�eY� 5'.�11ns5 tVL¢ss u,�¢ I> t' C.cyujwr fis ACCOUNTINOONLY: AIDS FACS PE CODES FEE INFO AMOUNT REMITTED CHECKIUCASH RECEIVED BY DATE PERMIT/SDIVICE REQUEST NUMBER INVOICE 0 Z�2Qa [2cf1 Pub.HeeOh Sere.-Envlro.173(3/96)