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P�F`7 APPLICATION FOR WELLIPUMP PERMIT �au��N.r ys' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIn.3 PAYMENT ENVIRONMENTAL HEALTH DIVISION I t`,IVOWO. BOX 3813, 304 EAST WEBER AVENUE, STOCKTON, CA 96`10i'88'_ i ;,.1LT11 Y 8 M6 (209) 469-3420 k,L N , IrdaIJINLfauFJTY g��l; 'i' LII i 6i.h TY NONREFUNDABLE PERMIT EXPIRES I YEAR FRBM BATE ISSUED; ", ,�';'� -^ Fj 1 2: G I N10R€fLVA4k$l �t�� 15fVIM10N ICompMLE in Tllpl'EEtBI ?A7�IC 1A JOAOUINCOUNTY FOA A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WON BAN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTTH SERVICES,ENVIRONMENTAL 14EALTH DIVISION. RESSIOR APN!?l 1� L 11 YFI 5 r12tc� CITYPARCEL SI2EIAITJI NAME ��> "\ � VL£1N! �C� ADDRESS p �'A ui�,J f�f� 15112'-5't`ID m10NE A0141�3�I'-S 7S'J _ Y7.1.q Ce r+I GLf LAI OIL .nS c l CONTRACTOR' LC "^ iT '•PAF '-n, S4C_{ yy C. ADDRESS' c - T1CIAIONEgL44��'C��R SUBCOWMCTOA E71-1 TT-%L ADDRESS S!V 1 I[� 449D1 ucE6246U1 MONS ka4'4bLJl TYPE OF M LMLIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL E ❑ OTHER j ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL 2 J ❑Ne 11R.P.I, H.P. DEPTH PIMP GET—Fl. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OW-OF-SERVICE WELL Cl GEOPHYSICAL WELL I SOIL BONING B I ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ DOMESTIC"IVATE ❑GRAVEL PACKISIZE TYPE OF CASINGI6TEELIPVC DIA.OF WELL CASINO O i ❑ %IOLICIMUNICIPAL Cl DRIVEN DEPTH OF GROUT SEAL [� SPECIFICATION R p` ClIRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED ByV C<'.9JTdc.CTO R GROUT BRAND NAME E 1 ❑ MON70RING OROVT SEAL PUMPED:JA Yr ❑Ne CONCRETE PEDESTAL BV OFULI❑Y. [IN. 5 APPROX.DEPTH \O r�-V: f L-� LOCKING CHHE�STER BOX/STOVE NPE w �` s PROPOSED CONSTRUCTIONIDNLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERI UL LCA C�Usv4 I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOM 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WATCH THIS PERMIT 16 ISSUED,I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COWRACTOR'S MINING OR Su"IDWRACTING SIGNATURE CERTIFIES THE FOLLyOWING: 'I CERTIFY THAT IN TIIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORMM'S COMPENSATION LAWS OF CALIFOR`J\�IAiE APPUC T MUS 110 WE IN ADVANCE FOR ALL REQUIRED IINNSPECTIONS AT 12"144SJ 22. COMPLETE ORALNNO AT LOWER AREA PROVIDED. slcrbd x �Q TRI. C'1ZOS Ec` PLOT PUN 031—Le eetl.l 6etl.� 'le 100 1. NAMES O STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPESTY. 4. LOCATION OF HOUSE BEWARE DISPOSAL SYSTEM On PROI'OSEU L 2. OUTLINE OF THE P110PEATV,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE LKSPdBR SYSTEMS. 3. 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 On ADJOINING PROPERTY. 0 f6; Il i u