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—"PPLICATION FOR WELL/PUMP PERMIT j 'SAIeimaUAOUIN COUNTY PUBLIC HEALTH SEI, CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)488-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I MAQUIN ON IB HERE BY MADE TO THE SAN"ADD M COUNTY FOR q ICompMb In TrlpReelEl ' JOAOUIN COUNTY DEVELO�PMFM TRIP,CHAPTER 9- PERMIT TO CONSTRUCT gND/Op INSTALL THE WpgE DESCRIBED.TIIie APPLICATION IS MADE IN COMPLIANCE 1116/,•3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH IN CONN, JOB ADDgE88/OR APAN/�'7•-W£ST T(a AN`A R 4 WRIT BAN OWNER'S NAME F \ t , I /C lot C 1 �-•�4 I L ' PARCEL BIZFJAPNI-- CONTRACTOR (^t'1�• �/y gDDRESe U(,L Pj Or/ v r'• JWL./q-� I'Yli C 66 RHONE Il LT70 —Z�avy SUB CONTRACTOR RICH&t.- /�(� 1�// ADDRESS l KRILL-1/VI / / C RHONE ADOVHE8 (, Vb LICI(Z7— � ry, PHONE 6 TYPE OF WELL/PUMP: MEW WELL 13 REPLACEMENT WELL -p( ROWI �T pl MONRINO WELL/ WI- ❑OTHER E LIS INSTALLATION C] WELL SYSTEM REPAIR ❑ CROGS-CONNECT REPAIR i MwY❑Repair H.P. ❑ VAPOR WATER WELL/ J RVPE OF PIM% DEPTH PUMP eET__FT, FIRST WATER LEVEL O I 1 ❑ OW"OFSERVICE WELL ❑ GEOPHYSICAL WELL• IJ ROIL ROVING ! 11 DESTRUCTION- I B INTENDED UBE :TYPE OF WELL - col,BT9OOl10N BPECIFICpiIONBO ❑'1 INDUSTRIAL ��OPEN BOTTOM DIA.OF WELL EXCAVATION p /I ,i A IJ DOMESTIC/PNVATE �E�1 H �MH,, DIA.OFCONDVCTORCASRIG -'�� p Jo.OGAVEL PACK/SIZE /Z TYPE OF CASINO/STEP/PVC_ p rVG VIA.OF WLLL CASING ZII p ❑NBLOIMUNICIPAL �'�U DRIVEN DEPTH OF GROUT BEAL��I/ SPECIFICATIONR S Y ?{fIGIL - 4 IRNOAiON/AO El BMW SEAL INSTALLED BY11 r�� GROUT BRAND NAME RECON I TiEp E RI1 19MONITORINB o f ;! BMW BEAL MPEO: ❑Ys %NO CONCRETE PEDESTAL BV DNLLER:O Y. 19Ne 5 k APPROX.DEPTH �O LOCKINO CHEBfE OX OVE RPE B r PROPOSED CONSTRVCTONIONLLINO METHOD: MUD ROTARY AIR VOTARY —AUGER _CABLE OTHER I HEREBY CERTIFY THAT 11RAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND 1 REGULATIONS Of THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIEB THE FOLLOWHNO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WON(FOR WMICH 71119 PERMIT Ie ISSUED,I B1/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUWCONTRACTINO 6IONATURE CERTIFIER THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WON(POR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' 7R'yE�ArW'PP,,(U,.[C�A�N//3 MV/{Bf/T�CALL2q',/L/I//�/�/R�E/�IeN�ADVANCE FOq ALL REQUIRED INSPECTION*AT 12000114M-3`423../COMPLE-TTE DRAWINO AT LOWER AREA POVIDED...{ Y�=L Tllte 1 R0 Tl16 1 L%tO W ISI S/ Det. V '.� PLOT PUN 0.to Soot.)Beota •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. /, LOCATION OF"OUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPOBAL SYSTEMS, 'i 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTINO AND PROPOSED B. LOCATION Or WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYB,AND WALKS. ON THE PROPERTY OR AOJOININO PROPERTY. .... __i_ FORMER ... ,i EXCAVATON BOUNDARY MW-1 - '^"'" FORMER .. _....:._ _. 15.000 CN.. 'k vi DIE50. NEL « . ..I ... g' UST UMO OF DIESEL NF1 .... .... '.. IMPACTED GROUNDWATER '. .... ! ¢ FORMER ; PIRNO I ! UW OF DIESEL NEL A IIMPACTED SOIL ` 1 S ` 9 5 AT&T BUILDING ® ` I X AK-P-PmOOnRn KEIL looms Sea.ee pXEeL emir•Ew Rfr FIC . I L :......;.. ..._... '....... .:...... ONLY..^- F^�. .....�A-+....._-`._ APPSeelbn Aaerytad BY ,L Dn.. L- D V _A,. D�• 0'.0 Irnpeelbn BI LI OsO ORmp Impsellen BY DH. Oeemstbn Inpeeeen BY It Dete ,. II ACCOUNTING ONLY: Alb/ 'I ,,-`` FAC.F PE CODES FEE INFO AMOUNT REMITTED CHECOCABH RECEIVED BY DATE PE@AITNERVICE REQUEST NUMBER INVOICE �S-ol 8`1 D 5 i Pub.Health Sam,-Enviro.173(1/97) € i h J