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APPLICATION FOR WELLIPUMP PERMIT 4N JOADUIN COUNTY PUBLIC HEALTH SERVICt. ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201'388 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (CGmpbto In Triplicate) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADORESSIORAPN/ I3 L��^�nn'G!_yJC� �"-5-�}'�G� CRY"/J l4/kjj,O�'��s �J PARCEL SIZE/APNO OWNER'S NAME ysQR .S (L`J( /9`ry(. T ADDRESS P'G,I,1A ty,r/ X�ygsr.e5 L,C,I-W 1%-3n PHONE 0-5&- CONTRACTORPQ(+ G- JI nS�+-Jr'r's�'-FX(J / VY.'� (YI.! ADORE68JL3,, 5S4,C.Y'�Y'{J.IXJ_.:•�.+: /, SUB CONTRACTOR�PP +i �X�IdIZT �! ADDRE88t's( Syler-J' �J IXC/`y PHONE 012O' TYPE OF WELLJPUMP. E NEW WEU. ❑REPLACEMENT WELL �I MONITORING WELL f 1(A� ❑OTHER {l-Js INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL f, J RYPf OF RUMP) ❑N.-❑R.pwr M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL f ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USETYPE OF WELL CONITRLX:TION SPECIFICATIO NE p q d 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CA8ING ❑DOMESTm/mvATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEUPVC 1'VG DIA.OF WELL CABING D 11PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 22.0 SPECIFICATIONGD a ❑IRRIGATION/AG OTHER GROUT SEAL INSTALLEDBY. !'1(` �fD�4'f o, MUT BRAND NAME E MONITORING GROUT SEAL PUMPED:❑Yr ❑Ne / CONCRETE PEDESTAL BY DMUFR:❑Y- ❑No s APPROX.DE"H LOCKING CHESTER BOX/STOVE PIP)E�� PROPOSED CONSTRUCTIONRRSWNO METHOD: MUD ROTARY AIR ROTARY AUGER X T!M/a+-%.-ii OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF CAUFORNIA.' HE AWUCANYT//,NNJfyT///�/CAU 24 IKUPA IN ADVANCE FOR ALL REOUNLELDD IINSK MNSS IAT IL/3,�W1�4/YJ43/1.COMPLETE DRAWING AT LOWER AREA PROVIDEDQ. erond X /�Z'MI -G� T16wF�%'I.l 11'q41 'T (�L'D L oa i S Y O.t. �( PLOT PIAN IN—Io 7".)Bowe •to I.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERLY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURE8,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. W M z I o V iS it ' SOUTH CENTER STREET + R�.v.sTWo.�iF�u�rvs PiteDUCT ISV.ND hurl p ♦ I srDenDr uw..s � Ia'• .. «.Twa ewt Drswa..non w+ nrr r . DRIB u,Dnrtna D vTI, Dr_«a.nD� RIA5TA01L�� SII eI I .o l��S� SITE MAP .. N --._,v... _... _ naOhC,.� 7.. DEPARTMENT USE ONLY APPIIwtlon Ao td By _O.t..__�_D Gout Irrp.eSM By D. Pump ImpmtIon By O.t• D-t,-teen 1-0-By Cemm.t.: 04 iowl's w.xmits ACCOUNTING ONLY: AID/ FAC/ PE CODES FEE IN AMOUNT REMITTED CHECKFICASH RECEIVED NY DATE PERMIT/SEFIICF REQUEST NUMBER INVOICE 1 05 3 3 lo. O 13