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At APPLICATION FOR WELL/PUMP PEI "MIT wYN JOAQUIN COUNTY PUBLIC HEALT !',RVICES '17 ENVIRONMENTAL HEALTH DMS 304 EAST WEBER AVENUE, STOCKTONI CA 95202.: (209)468-3420 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OTE ISSUED (Complete in TTiplkwl APPLICATION 08 NEM BY MADE TO THE.BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT Ai INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLES.CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTYY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMA APNI� E , I V 1 — S Q Q-- tCIT—Y �CC1 ltiC..�� PARCEL BREIAPNI OWNER'S NAME �- 1 L�� ADDMSS(OQ G• Il')IT� S-fT�P.e-i-'. PHONEI COMMCTOR�[`1nn�..r�IICI OUR CONTRACTORT't_C I I YNL [�y/PA-C1 rg"�i C30 ADDRESS��JGS LM�IAYtY1'L NN. me ProNE I t/(oS 7Ia- TYPEOFWELUPVMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL S- ❑ OTHER - ti•--w- --� - ❑ INSTALLATION ❑WELL SYSTEM REPAIR- +a'❑ CROSS,CONNECT REPAIR ❑ VAPOREXTRACTIONWELLF D N.11 Repelr N.P. DEPTH PUMP SET_R. I� FIRST WATER LEVEL O (TYPE OF RIMPI III ' '�y/H ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL S ❑ BOIL BORING B y}DESTRUCTION: V /INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL [1 OPEN BOTTOM DIA.OF WELL EXCAVATION -- IL, Ell DIA.OF CONDUCTOR CASINO O 13DOMESTICAISVATE ❑GRAVEL PACKNIDE TYPE OF CASINOISTEEUPVC CP'\ ,;lPVL DIA.OF WELL CASINO D 11PIBOMMUNICIPAL 1:1 DRIVEN DEPTH OF GROW SEAL 'I SPECIFICATION L R ❑ IRRIGATION/AU ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME E V-MONITORING GROUT SEAL PUMPED: ❑Ys ❑Ne 'I CONCRETE MOEBTAL BV ORIlEfl:❑V.. ❑N. B APPROX.DERN LOCKING CHESTED BO%KRONE PPE S ' PROPOSED CONSTROCEIONI LUNG METHOD: MUD ROTARY AIR BOTANY AUGER CABLE OTHER 1 HMBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MTN SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND - REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT m THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,181/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTNACTOWIL HIRING OR SUB,CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CEBIIFYTRXT"S IE PERFORMANCE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATOR LAWS OF GUFOIBJI/AJ�N,E APPLICANT MINT OA a +/HOURS IN DVA CE FOR ALL REQUIIFD 1 PE G le wT ITOSI+YSIis;1 PISTE DRAWING AT LOWER AREA PRO ED. MOT MAN 11)11.B.N.1 Bd.i. -He ') 1. NAMES OF STREETS ON ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE mePOSAL SYSTEM OR PW MBED PR 2. OUTLINE OF THE OPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. ',i EXPANSION OF SEWAGE mePOSA-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 WAUCS. i ON THE PROPERTY on ADJOINING PNOPOI Storefronts B-11 _. . MW-4 R ,... 8-13� 0 B-10 B-9 Bel 2 1 C B-3 10th Street. ... MW ' M W-3 .. /Farmer'O5T Location 7 9 5 ' Fortner Pump Island _ _. AUfG MIV2 -EiR sF DEPARTMENT USE ONLY Appllvetlen Awepted By �>�./-� - (O r '4 GO. 7_ �� L / Mse L7,7 0'.0 IMpeallen a �/vrf D.t. Pmp ImpecBen BY beelnw:lbn lMP.Illen ev �W"1/ I �../+ Dela V+�'��'�-U Cemme•Ne: /O as.O�/�a:t21�(, ��' ✓/ �YI.P/�- ^p '� MJ GJI - Jw — — ��I .A —7-/z2- FA.....11. - ZLACCOUNTING ONLY: MDR FACS PE CODES FEE INFO AMOUNT REMITTED HEt MASH RECEIVED BY DATE i� PEIMITISEAMCE REQUEST NUMBER INVOICE 35-01 v cY or Lo q i Pub.Health Serv.-Enviro.173(1/97) '.!