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t APPLICATION FOR WELL/PUMP PE� JOAQUIN COUNTY PUBLIC HEALTH ,CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNUABEE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TIIpReabl APPLICATION IS HEAR BY MADE TO THE BAN JOAOOIN COUNTY FOR A PERMIT TO CONSTRUCT ANDPOR INSTALL THE WORK DESCRIBED-TIII6 APPLICATION IS MADE IN COMPTIANCE WITII SAN JOAQUIN COUNTY DEVELOPMEENCNT//-TEETTE,CHAPTER 9.11151.3 A.LNDD THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTII SERVICES.ENVIRCNMENIAI HEALTH DINSII{O�N9. z JOBADURESSEORAPNI FrY]L_J VICT L-AIJE CRY_ '--F/D I PARCEL& A%M (' ( 1- US- 3 OWNFR'RNAME GaUIL-01j E I l e ADDRESS F'0. B0x6249 , CA-RSOni CA9o7F9RIONEI( 9) N5-99ob CONTRACTOR C4RESa(a -C)(ZILLIEJ(Q ADDRESS 950 µOWE )a> HARTlEAIcI -4fi5-iAE&mNEI tg!Fj 3/3-54'00 BUS CONTRACTOR ADDRESS uclPHONE I TYPE OF WELIRUMP. ❑ NFAIWELL ❑ REPLACEMENT WELL ❑ MONT ORING WELL IT ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL P DYPE OF RIM% ❑N—❑HeeW Kp. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OAT-OF SERVICE WELL ❑ OEORIV6ICAL WELL I US FOIL FIBBING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DA.OF WELL EXCAVATION RIA.OF CONDUCTOR CASINO G ❑ DOMESTICM1`NVATE ❑GRAVEL PACX/ E TYP[OFCASINDSTEEVP RIA,OF WELL CASINO B ElRIBUCIMUNICIPAL ❑DRIVEN OEM"OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING �1 (//TL TG �/J GROUT SEAL RIMPM: ❑Y- 0 N CONCRETE PEDESTAL BV 0110.1ER:❑Y. ON. 5 ApR10 X.OEITH 1( I 1 I D'If-,l V LOCKING CHESTER SOX/STOVE PPE g PROPOSED COMSi1111C110NmRIlLMG MUM., MLAO RO AIR ROTARY AUGER_CABLE OTHER I HEREBY CERTIFY THAT I NAVE PREPARED THIS APLCATION AND THAT THE WOW WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS AND RULES ANO REGULATIONS OF THE SAN JOAUUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOYANG:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,18IHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALJFORMA.- CONTRACTOR'S HIRING OR SM-COHTRACTMO SIGNATURE CERTIFIES THE TO OYANG: ' C RIFY THAT RI THE PERIFORMANCE OF THE M FOR WHICH TMS PERMrt IB ISSUED,1 SMALL FM0.0Y PERSONS SUBJECT 10 WORKMAN'S COMPdSAT10N LAWS OF CAUFO M CANT MRHT CALL II I O_6 IN ADVANC!FOR ALL REOUMFD INaP/SICT/n1N.S/AT 1]eBl Atl.iAe//i]. COnMP��E/TE/�DRAWING AT LOWER AREA PRO,V�IFD,E//O}.��// «RIM X TIN. (}�/T/,� ( Cil, �HF�/l✓C-�D.t. / /!J� sP ROT MN Or.RI tP B.. , 1. NAMES OF STREETS OR ADS NEAREST TO OR BOVNpNp THE PROPERTY. l LOCATION OF NOUBE BFNAGE pBPOBAI SYSTEM OR PlVllb6E0 S. OUTLINE OF THE PROPERTY.GAM DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ]. DIMENSIONED OATLMFB AM LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS VJRNN RAOMS OF ONE NVNOREO FIFTY FT, STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT THE ONLY l % /, AePlbNbn Aaalgled BY �.I/Y- /X' 1%V_ DN. MY mmol IrwermlbR eF I D«. A21 BY Dn. O.wrn Rlbn Imn+lbn Y D«. ACCOUNTING ONLY: AIpI FAC# PE CODES FEE INFO AMOUNT(^, REMITTED CHEciarmnSN RE BY J DATE PERMITISPAVICE REQUEST NUMBER INVOICE y Pub.HHNdIh SON.-Enviro.173(I/M L