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OPLICATION FOR W /PUMP PER MI PL ooJ42/WD SAN&OUIN COUNTY'UL HEALTH SEFES ENVIRONMENTAL HEALTH DIVISION / p 304 EAST WEBER AVENUE,STOCKTON, CA 95202 /viT,c 1 ( 468-3420 NON-REFUNDABLE PERMITRMIT EXPIRES f YEAR FROM RR7E ISSUED Q R I'N A (Complete in TripliG111) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT //TRUE/:CHAPTER 9-1111115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/011APNI �7(O Vl.I..J�e lAJ l 2 A.J�P✓l CITY��'O l PARCEL SIZE/APNI y{.(; ,�{'pry CPAn...:.•g ae P.•Od.-ACJ (s x e ti T) 7? Pew��orI, OWNER'S NAMECtDon a e r,'8 M¢54..,JY[GtlINP Fr''a ZPeP ADDRESS FN..��JJ//F�A�rY V4 Of' -/F.7 PHONE#'s/0-&S CONTRACTOR ADDRESS LICI PHONE .tics w;yaaa. 'D'. SUBCONTRACTOR SPe0,xy.YL ADDRESS Sf , r'A 9SZOS UC.C.$7-.r/.?I°69 PHONE TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL A_l MONITORING WELL I L0O5A-:>— ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J N.13 Rep.lr N.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL 0 R VPE OF PUMP) �1///)�-I�T L� ❑ DVE T-OF-SERVICWGEOPHYSICALLL ❑ GEOPHYSICAL WELL ❑ 601E EGGING B xDESTRUCTION! 5'ee /� CN,,�/ FO& /17r �, V Wo/t-,C INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �y I A 11 INDUSTRIAL 0Ip�OPEN BOTTOM 7 DIA.OF WELL EXCAVATION S� K (J DIA.OF CONDUCTOR CASINO �? 0 ElDOMESTICRW VATE (BGRAVEL PACKISIZE_ yjTYPE OF CASINGISTEEIRNC) 2 H DIA.OF WELL CASINO , IZ ,1 O ❑ PUBOCIMUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL S`Q / SPECIFICATION SCtJ yQ ✓Gyyp� R ❑ IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY O1�I IIQti GROUT BRAND NAME CCTIaW/T/TqypLW/UNr T'Q E MONITORING p GROUT SEAL PIMPED: PVr (IN. CONCRETE PEDESTAL BV DRILLER:y�V.. ❑Ne S APPROX.DEPTH RD / LOCKING CHESTER BOXISTOVE RPE S PROPOSED CONSTRUCT1ONIdtlLLINO METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOIK FOR WHICH THIS PERMIT 19 ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HINNU OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT}MUST CALL-,P4 Mq IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT H1011014411141COMPETE ORAWING AT LOWER AREA P11OMO TR,. SPNrOn' Ut 901"G/5% o.Ie b/�� POT PIAN IDL.Ie Sed.)Se.b 'W 1. NAMES OF STREETS OR ROAD9 NEAREST TO OR BOUNDING T14E PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOMID Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. M I}p !�f it 0- c.�+ Pz- oos"R -a DEPARTMENT USE ONLY R Q APPRc.S.O Ac.pl.d By D.l. V• �5•�� Mu OW" Gmul lmPectlon IS D.,. P—,ln.Peenen BY D.I. Ue.e•stlen lmnecllen By D.I. Z Z c.mmm�I.: �j/I �1 d J Z l�l ACCOUNTING ONLY: AIDS I FACT PE CODES FEE INFO AMOUNT REMITTED CHECKI/CASH RECEIVED BY I DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3502 gz S z o/6&el Pub.Health SEN.-Enviro.173(1/97)