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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERViCT ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (2091468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED MomPleff ITrIplil APPLICATION IS HE GE BY MADE TO THE BAN JOAQUIN COUNTY FOn A PERMIT TO CONSTRUCT Al(INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE Al SAN JOAQUIN COUNTY DEVELOPME(NT T"JREE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESe/Ofl APNf �./3J F:L i �_ I-I ti Lr..V,( LIgIGL\ l�I\ �- _-St11cKil n C_�A 1� r , L clri OWNER'S NAME 3=L10 D GPO �n i.,piCAE,pn�S PARCEL SRE/APNI swak aFe1P �uw1d ,QCQdS\wR,S; Qv3tsk f\ane 1 ADDRESS III QOuxl\5� 12 F10f Ile C(\ II � PHONEf LCVipee Tl'TL1�•RZMEN Bne eaP RUB CONTRACTOR�f 1�P IJ 1 1-�TC.� RK)Nf• �. T/n-Si\,AIY1L ADDnm ISO kOWf. I�• r1eRvr ne} Ifs- 'S 6S PHONE 0SID 313'SBQQ TYPE OF WEL MUMP' ❑ NEW WELL ❑ REPLACEMENT WEIR ❑ MONITORING WELL I 13 OTHER ,� ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROP&CONNECT REPAIR Al❑N.El ❑ VAPOR EXTRACTION # RVPE OF PVMP R.p.B N.P. DEPTH PUMP SET FT. -- FIRST All LEVEL O p,N,,_111�� \\ ❑ OUT-0F SERVICE WELL ❑ GEOPHYSICAL WELL, ❑ SOIL BORING ❑DESTRUCTION:— S`\Ll \D`Ik LNQ C ` &/`� B D'LPALT L7NJ�� INTENDED USE TYPE OF W CONSTgVCTIOH tpECIFICATIONS ❑ INDUSTRIAL ❑OPENBOTfOMA DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/6TEELJPVCD 11PUBLIC/MUNICIPAL ❑DRIVEN DIA.OF WELL CASINO D DEPTH OF GROUT SEAL SPECIFICATION ❑ IPRIOATN)N/AO ❑OTHER GROUT SEAL INSTALLED BY A ❑ MONITORING GROUT BRAND NAME F GROUT SEAL PUMPED: ❑Yee ❑Ne LOCKING CHESTER APPROX.DCONCRETEPEDESTALSYDRILLER:❑Ys [IN.. S EPTH STER BO%/STOVE RPE PROPOSED COMSIRIICTIONRRRAHMO METHOD: MUD ROTAM T S AIR ROTARY AUGER CABLE OTHER 1 1 HFREBV CERTIFY THAT I JOA PREPARED THIS HOME O TION ANO THAT TNA WDRIC NSLL BE OONF IN ACCORDANCE WITH SAN JOAOVIN COUNTY oRDINANCELL STRE LAWS,AND RULES AHO REOIRATION6 OF THE RAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGE SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORE(FOR"ICH THIS PERMIT Ie ISSUED,I$HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOW": •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.- T A ✓CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOM W INSPIECTIONS AT MUS)ISSOA22. COMPLETE DRANSNG AT LOWER AREA PROVIDED. III x,� •-/�- - 4 Q�ent fDr �i*ea"6P`+nH1Son INS.. CPT Q�t kt s Maw,g Dete PLOT PLAN(Drew to Ill Bels1 •Ie �SQI 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, L LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED O. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL RYRTEMR STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS, R. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. 07 ® wlao s® CPT-100 M W 10 ` MW 101 1 MW11 ®5 3 2 \, C 10 4 Chevron \ CH Gas Station \ CHMW-3 / `12 MW3 pPCIFjC Avg �� 13 CHMW-7 CHMW-6 ®orecr Station 14 DEFMTMENT USE ONLY P101 I.n A..epled BTJ_L / " "� 4' l V • L / _. . O.I._ M.. all Impe.Ibn BY-. G Dere F -Y.L.n By Dele Ominlenen Imnepeen BY ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO MOUNT REMITTED CIIECKf/CAS1/ REC13VED■Y DATE PORMIT/SERVICE REQUEST NUMBER INVOICE 3� (a•tD.q�► 012 y Pub.Health SRV.-EnVITO.173(3/96)