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I "PLICATION FOR WELL/PUMP PERMIT SAN IPOUIN COUNTY PUBLIC HEALTH SERV.:.cS ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (ComPkto In TrbrkoTF) APPLICATION IS HERE RY MADE TO THE SAN JOAOUIN COUNTY POn A PERMIT TO CONSTRICT ANIT/OR INCTALL 711E WORK DEG(;NBEO,THIS AMMATION IS MADE IN CIHA LIANCF VM 11 SAN JOAOUIN COUNTY DEVLlOP'ENENT TITIE„CFIAFTFJrg,-,1�1 75.3`/ASND THE STANOARD11 OF SAN JOAOURE COU+NvY PVBLJC MEALTH SERVLCES.ENVIRONMENTAL NfALTH dN61DN, (It JDB AbDRE65ATR APN/!µ1 S7�yY�J l�1ld-[CG''�/0I lG[WTd�f�l_l�4h -9• CT' 1 r9mc V _PARCEL SIMAPNf �73 ar"C OWIIER'S NAME i'FiIF1Lw Ll.-JI/1. ( TaI/+ kirk-) ADDRESS PCa_l X+�I.S /� Pr/L}�f5 by;H PA 91- CONTRACTOR (,fewi Driflim) RlAd'Tr-s+im,IrIG ADORES9r150 P&Wf kdl- l"'��•LCF HX',.7r�t►SIHONEI�I'� �j�"✓�'S�c' PUB CONTRACTOR ` ADDRESS - UCF MIDNE/ ea�s.a. 1 E-y F-T •• -� TYPE of WELLMUMP; ❑NEW WELL ❑RFPLI.CEMFNT WELL E❑MONITORING WELL/ CI OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR C3 COOSS-CONNECT REPAIR ©VAPOR EXTRACTION WELL F J ❑N..I❑P—w H,P. DEPTH P M`P SEY__,_-_FT- FIRST WATER LEVEL O HYPE OF PUMPI Ty 11GLTOF-6ERVICE WELL ❑GEOPHYSICAL WILL R , BORBONNO 8 ❑VESTRLICTION &rTL44 lvdf /Dwli"'d T" SUFTV iv* JlllliIM1&`- JA(� tC*kq"y INTENDm ULE TYPE Of WEEL CONSTRUCTION PPECNICAiION/IIS, A ❑1NVUSTR IAt ❑OPEN ROTTOFA DIA.OF WELL EILCAVATION �!'t/• bIA.OF CONOVCTOR[A61NU MIA O ❑DOM SUCA'NVATE ,❑y ORAVEL PACKI817E TYPE OF CA61NGIGIEELlPVC ✓^JfA ///,,,//I DAA.OF WELL C ASINO_ )WA O ❑M1RUClMVNMIPAL 10�J DRIVEN ``�`, �T DEPTH OF GROVT SEAL � 10:7�iZ'1SPECIFICATION MPA R r❑IRR OATIONNIG 'MOTHER 5,j e GROUT SEAL INSTALLED�S{Y �-E pRO1TT BRAND NAME F�-E f L'J MONfTONND ! 'Y7J GROVE SEAL PIMPED:ICIY- ON. 2, `CONCRETEPEIAGIALOYDRILItMOYw _BIN. 5 AtMON.DEPTH 10-/2 LOCKING CHESTER BORBTOVE PPE N/A ,y S PROPOSED CONBTRVCTIONIOROLLINO METHOD: MUD ROTARY AIR ROTARY AVGER CABLE OTHER V/^ft,00 L J( anFwP r 1 HF�WBY CERTe THAT 1 NAVE PREPARED TMe APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAOWN CDUI T ORDINANCES-STATE LAWS,ANP PULES AND nECVLAT1pN9 OF THE SAN"AD"COVNTY-HOME OWNER OR LICENSED AGEM-S SIGNATURE CERTIFIES THE FOLLOWING:Y CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR MACH TMF PERMH It KwED.1511ALL NOT EMPLOY PERSONS SUBJECT TO WIIA MAN'S COMPFNSAMN LAWS OF CALIFORNIA;CONTRACTOR'@HRNNp 01%CU6[OWRACTIN1 C1004ATM CERTIFIES THE FOLLOWNO: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORT FOR WHICH THIS PEPMR 10 HIGUED,1 SHALL EMPLOY PEnSONB BUBJECT TO WORIOAAN'S CO.MSATION LAWS Of CALIFORNIA.- I'M A-P LIICAANT MVPITyCALLLL N l/IS IN RD ANCE FOR ALL REOUIRm INSPELTIONS[`AT L2PMH 4e*4423.COMPLETE DRAWING AT LOWER AREA VnOVIDEO.y G a...e J1 �� TIPN c/1I/ 7�LrKT-E's� D.t._-_ -,�/•"97 Y - V PLOT MN PIN.w I•R•.I•I Oe.NI. 1.NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING TETE PIOMAREY• A.LOCATION OF HOUSE SELVAGE OIBPOSAL SYSTFAE On PROrxiGm 2.OUTLINE OF THE PROPERTY.OMMa OIMFNSIONS AND NORTH DIRECTION. EXPANBION OF SEWAGE DIBVOBAL SYSTEMS, J.DIMENSIONED OUTLINES AND LOCATION Of ALL EXISTING AND PROPOSED S.LOCATION OF WELLS%WMN RAbrue OF ONE HUNOILED IIFTY rT. STRUCTURES,INCLUPLHD COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALK& ON THE PROMPYY OR ADJOINING PROPERTY. , : . .. , DEPARTMENT VIE ONLY ApAft.Uen A--,.OY R.�..ln.nr.,ten Br O.!• Pune Im•..Nen BE DHP OrnRIucRNn Imnlellen RY�, �"�" b.1. Ee... :(^"av o � 1L'r R_�-�,L.E-•t„Id."1_ h. t-�5rh ►'+1 s-f ACCDUNFINO ONLY: AIDI FAC/ %,L•J l-� PE CODES FEE IHFO AMO URT REM17M CHECK/ICARH RECDVEO 11Y DATE PCIFNI TIMER TCE REOUEAT NVMS9R LHVOICF T Pub.Health Sem.-Envlro.173(1197) i