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APPLICATION FOR WELLIPUMP PERMIT a„N JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 (209)488.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED (Comple ei JOAQUIN COION N HERE EL MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUICTIAND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN APPLICJOAOUIN COUNTY DEVELOPMENT T2TlE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADORESS/OII APNE_ {_3� y �GPy,J-rrS-fy>_cF CI /? /'j ��TJ �J / PARCEL SIZE/APNI OWNER'S NAME e• LC// 1 /`sem ADDRE88 f,±,130,61%-1 S',, /SQs�•ra /f/ R/= `,/PH,O,NE/�2�Y�-4I69� COHTMCTOR ((''11 ` V .� H:}-� /7Y-C• jy, ADDRESS ._S , :� y�J• Lk�s ""'`”"PHONE F9lF= gym• BUB COHTRACTORyZ ,--b h -� _ _XD G1arT'6 1 tl ADDRE 88�--^ G/'M.. Yjy UCf - PHONE 012LI,- `i'5� . T."1-�• 9�S i G �7 1 TYPE OF WEWRJMP ;NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELLI ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR M VAPOR EXTRACTION WELL ESv.r RVPE Of PPM% ❑No.❑R•ow, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL +l- J ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL I ❑ BOIL BORING 8 DESTRUCTION: I�N-sT FNOED USF Y►E OF WELL CONSTRUCTION SPECIFIC ATI ONE J INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONn� DIA.OF CONDUCTOR CASINO_NA C ❑DOMESTIO/PPJVATE 11 GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC T IIL DIA.OF WELL CASING ,Y/ D ❑PUBUCRAUNICIPAL ❑['�DRIVEN DEPTH OF GROUT SEAL_ —/0/ SPECIFICATION SG�dKIG�d ❑IRIBOATON/AO ,►'Jj OTHER GROUT SEAL INSTALLED BYayaP-'h^((�.1�T�/ {-e;t GROUT BRAND NAME E ®MONRORINO GROUT SEAL PV RAPED:❑V« ❑Ne CONCRETE PEDESTAL NY DP1U..ER:❑Y— ❑N. 5 AP•ROX.DEPTH LOCKING CHESTER ROX/STOVE PIPE / F PROPOSED CONSTRUCTON/ORIWNG METHOD: MUD ROTARY AIR ROTARY AUGER {�dI-SLAB OTHER HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONEIN ACCORDANCE WITH CAN 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 WORK FOR WHICH THIS PERMIT 18188VED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIP1N0 OR SUBCONTRACTING SIGNATURE CERTIFIES rHE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIN PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAIJFORMA.• TRIF APK)CANT MUST CALL 74 HOW IN ADVANCE FOR ALL REOURm INS►QCTIONE AT(2"l M!-N/I3.COMPLETE DRAWING AT LOWER AREA PROVIDED. SI—d X �C/ ntl..Sex.ia Si-:�t� c le( D.t. la PLOT PLAN IDr•.v to S-I,j 6wb IP I.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. T.DIMENNIONED OUTUNEQ ANO LOCATION OF ALL EXISTING AND P STRUCTURES,IPROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT NCWDINO COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. -zze N Ia II � I I I > O , D SOUTH CENTER STREET nnszort,woMuouRo aucE rM,s -rar �Isunc mn nw • a ®uws ss• u a, i— res xm nvsnr;..su.I.x..nw+ ... ` =m.w��a a w<orxcaouuo � W�+�.•o oEs�rR..twR sl \ • saa inaiw IW W"ro"rra aa�rxn i 'T—�G�w...' w' I I ; M„JQ IM.,rMN nw PGill iNannN w' . ,`\,®.••. 111 _ I v W ' rn .P FEE' SITE MAP .�._.�..,�»� ratla•.wr; W E-+.ia+, �r+OJE -.r.... EiGURE 2 OFFMTMFNT USE ONLY �//�j�� APPIIP.Ibn Aa—F,.d BY - "- R {/ D.1• IV//��'2✓' / / A,— G r.ut Inp«Ilon BY D.I. IF—1—11—BY D.I. D«Irsxtbn IrvP�«ytbn,�BY D.I. c.—.: V/L 5 4<:f ACCOlWTNO ONLY: NDE FACE PE CODES FEN INFO AMOUNT REMITTm CHECKNICASH RECEIVED NY DATE PERMIT/SEANCE REQUEST NUMNER INVOICE 1 8 053 7 35