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' yr APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 300, 446 N SAN JOAQUIN ST,STOCXTON, CA 56201 380 1209) 4118 3420 0011 REFUNDARLE PERMIT EXPIRES,I,YEAR FROM DAZE ISSUED [Complete In Trltilkif*) Arpl' ICATION IS HERE BY MADE TO TIIE SAN JOAQUIN COUNTY FOR A 1`EnM1T TO CONSTRUCT ANDIOR INSTALL T}IE WON'DESCRIBED TIPI3 AFRICAT IDN 111 MADE IN CDMi11ANCE YAf 11 6A11 JOAQUIN COUNIY DEVELOPMENT TITLE CHAPTERS 1116 3 ANO THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HE At III SERVICES ENVIII0r1P IENIAL NEAL7H DIVISION A 100 AUGGE68JOn APIA# �GOy SOU'a^}I S'rRE EY" CRY 5?-O4I5'moo All PARCEL SIZFIAPNE yp Ag OWNERS NAME C11 4e.,'r...--3£ AA A13 a GA T-A7e7 PO, "Ox 20'Q SlbthluJ CA RS 2.04 NiONEt 209 9118 74T3 CONTRACTORb 3 35 SVNR,SG JSLIIA *#'4 ' 1 ADOIIE66 ! C r,o6 utl,aALIC# PHONE 1-ii-15_Z9fI 8 co-Sla2 SOB COWnACTOR 4 k) AA i t-z—a ra, ADonESi 15 ES rSdn 4,AT ucs }IOC7v TINONEI h2 j?`1 ZJI-T ISTA A L � TYRE OSE N1ELlP_Uqs ❑NEW WELL ❑REPLACEMENT WELL MONRORINO WELL f MIUQ A'ILJ 13 ❑OTHER ' ❑INBTALlARION ❑WELL SYSTEM REpmn ❑CROSS CONNECT REPAIR ❑VAPOR ExrMCT10N WELL f J ❑N-0 R•p.I. HPAj A DEPTH PUMP 6ET_FT fInST WAT III A EVEL^ (TYPE OF PUMM ❑OUT-OF SERVICE WELL ❑ GEOPHYSICAL WELL f ❑ 604 DOFMI043 p 1-1 OES7RWCT]ON ENDEP USE TYPE OF WELL CONSTRUCTION SPECIFICATION* A 11INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION 14 XAOGSI 11 DIA OP CONDUCTOR CASINO AjA p ❑DOMEBTICATIVATE ❑GRAVEL PACKISIZE TYPE OF CASINO/SI LE44VC II DIA OF WELL CASINO 44-ICA Gt, p ❑PUBIICIMUNICIPAL ❑ONVEN DEPTIl OF GROUT SEAL .Z 1 1,* SPECIfICAI ION S41.Gc1JE4 qu FJC- A }1 INYOATKENIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND FlAh1E E 1Af [IN.OROUTOMPLIMPEO MY— Ne ,CONCRETEIYDFSIAL 6Y ONLLER KY— ❑Ns S, APPROX DEPTH �S BO F[_E LOCKINO CIABILR / BORIS LOVE PIPE Ix1j f/Z AFFIL IOVEJR S PROPOSED CONCTRUCTIGNIOPoLUNO METHOD MUD ROTARY AIR ROTARY AUOfn X X CA01E OTHER I ' I HE9EBY CERTIFY THAT 1 HAVE pnEPAnEp T1116 APPLICATION AND THAT THE WORKWRL BE DONE UI ACCORDANCE Mill BAN JOADUIN COUNTY 0110MANCE6 STATE LAWS AND RU12*ANO REGULATIONS OF THE SAN JOAQUIN COUNTY HOME OWNER OR LICENSED AGENT B SIGNATURE CERTIFIES TRWI E FOLLONO 1 CERTIFY THAT IPJ THE PERFORMANCE OF THE WORK FOR WHICH TIUS PERMIT 16166UED 1 SHALL NOT EMPLOY PERSONS SUBJECT 10 WGGKAAAN a COMPENSATION LAWS OF CAUtOANIA CUNTTIACTOR 0111167!0 0R SUB CONTRACIM MONATURE CERTIFIER TIIE FOLLOWING IC REIFY THAT IN THE PERFORMANCE OF 711E WORK FOR WHICH TNI*PERMIT IB 16BUED I MALL IMr'LOY PERSON*SUBJECT 10 WORKMAN 6 C00AMQANON LAWS 0 CALIFGNGA [A CAH Utf ALL21 iN ADVANC[FOR ALL REGUIKFD INS riGNdGAY,_12001400-34y23 [COMPLETE DRAWING, LOWER MpEA p}fryl/ 619-d X `V" PLOT RAN IDI—IP B-1.)OPrI. t. ...... I NAMES Of OTREETa OR Wh00 NEAREST TO OR BO UNDING THE PROPERTY IOCATIGH OF IIOU6E SEWAGE p10pOt Al OYa1EM OR PInPD6ED I 2 OUTLINE OF 7HE PAOPEnTY GIVING DIMENSIONS ANO NORTH DIRECTION EXPAN61ON OF SEWAGE DISPOSAL SYSTEMS 3 DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S LOCATION OF WELLS WITHIN RADIUS OF ONE 1WHOMG FIFTY FT rIAUCTUFIES INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS a ON TIE PROPERTY OR ADJOINING PROPERTY a I o I SCF AT�I'A c11 c-A A.I q P I i ktF+:A Tp f 0)xr.fttl- A4n6-4 41/O 1 I I s ' DEPARTMENT USE ONLY AP11-11n APPPPird By U.I. kr f Grout In•Pxllrn BF D.I. Pune I—Pwunn BY Dar uwlru:U.n LrP-0-By D•R. � C--I. ' AGGGUNTiHG ONLY AIp1 FACE PE CODES FEE INFO AMOUNT REMITTED CNECKIICASH RECEIVED BY DATE PE7VvOtISERNCf REGUEST NIw0100I INVOICE 1