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��~!.. 4PPLICATiON FOR WELTU MP PERM'` Y SAOAOUIN COUNTY PUBLIC ALTH SE, CES . ENVIRONMENTAL HEALTH DIVISION •� 304 EAST WEBER AVENUE, STOCKTON, CA 95202 l_ (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED ICompkb in Troffealel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE V40RK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TrtU.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. - 164E fa , si JOB AOORE88lOR APNIG CrTr PARCEL SIZEIAPNI PIptA 113�r7 O-7�p'—1-7 OWHEn•B NAME `U!.Y,l.l_5..A, y). - ADDRESS 2-Mi � iia , �{u FO�2A11 BWbTPffONE LAAA CONTRACTOR Abb i;o D - aC °)467uc, -�1o07 PHONEN7a7.3�4.43r�r0 SUB CONTRACTOR ADDRESS LX)N PHONE, TYPE OF NIE,LLIPUMP: NEW WELL ❑ REPLACEMENT WELL MONITORING WELL,�1 ❑ OTHER INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 J ❑New❑RePNI H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL N Z�Pt. Pqs O RYPE 6r PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL, ❑ SOIL BORING a . ❑DESTRUCTION: INTENDED VSE TYPE OF WELL u CONSTRUCTION SPECIFICA IONi -_ "'� ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION t1 DIA.OF CONDUCTOR CASINO N/-A D ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEEVPVC__.7p DIA.OF WN L CASINO ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL INS SPECIFICATION G R ❑ IRRIGATIONIAG OTHER GROUT SEAL INSTALLED BJTTIZEALE P1 eE GROUT BRAND NAMEO L..}1 G p&"L- MONITOmmGI'j GROUT SEAL PUMPED:X-1- ❑No CONCRETE PEDESTAL BY ORIIL'R.gY. ❑No S APIrf10 X.DEPTH I Dy T.00%ING CHESTER BO%IBTOVE PIPE� S PROPOSED CONETRUCTIONIDRIVURO METHOM MUD ROTARY AIR ROTARY AUGER itsA_CABLE OTHER 1 HERESY CERt1FY 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 BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'@ COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOSK FOR WHICH THIS PERMrr IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENAATION LAWS OF CALIFORNI APPl1CAMT MUS A HOUR/�fS IN AD ANCE F R ALL REOUIRED INSPECTIONS AT 120@1 8!14422. COM E DRAWING AT LOWER AREA PRGO�VIDED, p i `DIN A sC / bets / O Bt9ned% TMe PLOT PLAN Dew to Seolel Seale `to 1. NAMES OF STREETS O ADS NEAREST TO OR BOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AM PROPOSED S. LOCATION Or WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH All PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR AOJOIMNO PROPERTY. STOP (m MDR 11 -1 1 1 ' F9" 1 1 lf(ttlD RfS�ENlui 1 1 ` ve-1 a YOsyIf91tA1G Vm LUG TN wm MicO lim 1tr-t a 1� 1 Slow r F�p��r�p�� 19tT ► IN7 % NP 1 1 r.aFma1 1 Ok STATION0 11 11 r�wt� 1 1 BARK OF AERICJI l 1 8 1 a NEEMEZZEKn so FT 1 POW.L01 1 1 SOU=: RGUS[rpulft[D FSOY GRaru+G PaovIGED I - BY PACIYIC DfYtAO1@IENTAL GROUP. NC. DEPARTMENT USE ONLY Appticetlen Ae-vted BY Dole ' '"`�'"- Grout'NnpeeifeSi"Bjr �.. Dote G Pu p Inspection By Data�- '� .� -�— De+tntellen 1nePeelbn BY...- CemmetNs• _ �yi � tl ACCOUNTING ONLY: AIDS FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK9ICA2H RECEIVED BY DATE PERRL TINERMCE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(1/97)