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} APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209) 468-420 N NON REFUNDABLE PERMT EXPIRES 1 YEAR FROM DATE ISSUED rA mplets In TrifReatsk 16APPLICATION 18 HERE BY MADE TO THE BAN JOAO"COUNTY FOR A PEWIT TO CONSTRUCT AND)OR INSTALL THE WORK DESCRIBEO TINS APPLICATION 18 MADE IN COMPLIANCE WITIR SAN JOAOUINCOUNTY DEVELOPMENT TITLE.C/HIAFm 9 1115 3 AND THE HTMIDARD8 OF SAN JOAQUIN COUMT PUBLIC HEALTH SEFMCEII ENVIRONMENTAL HEALTH DIViMON JOB AbOREGWR APN! // 1 / (Ovol CITY A' � �y�/Y1 PARCEL SIZEIAPN/_ OWNER B NAME 464L O ADORIESS Y7b y✓ �Jr 04.621 C PHONE R CONTRACTOR /''v ADDRESS QO );D �S Lie#, FHONEr 707 F)r.F RUB CONTRACTOR [r!I'paa ADDRESS J6 A �: PHONE I TYPE OF ❑ NEW WELL ❑ R04ACEUENT WELL ❑ MONITORING WELLS ❑ OTNER ❑ INSTALLATION ❑ WELL srsTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL s J ❑Naw❑P.,& H P DEPTH PUMP SET FT FIRST WATER LEVEL O (TYPE OF PUMP} 13OLROFER SVICE WELL ❑ GEOPIIYBICAL WELL R �BOLL C&/ BORING S ❑DESTRUCTION INTENOEO USE TYPE OF WELL CONSTRUF71ON SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION INA OF CONDUCTOR CASINO O ❑ DOMESTICIPRIVATE ❑GRAVEL PACKJStZE TYPE OF CASING187EEUPVC DIA OF WELL CASINO D ❑ PUBLICMUMCIPAL ❑D1aVEN DEPTH OF GROUT SEAL SPECIFICATK)N A 01 ATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME a ❑ MONITORING GROUT SEAL PUMPED ❑Ya. ❑Ne CONCRETE PEDESTAL BY DFULI EFL❑Y- ❑Iia s APPROX.DEPTH LOCKrNG CHESTER BOXISTOVE PIPE r s PROPOSED COM IRUCTIONIORRUNG METHOD MUD ROTARY AtR ROTARY AUGER CABLE OTHER I-- I HEs1ESY CERTIFY THAT 1 IIAVE PREPARED THIS AFPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES AND REOUL/LTIONS OF THE SAN JOAQUIN COUNTY HOME OWNER ON LICENSED AGENT'S SIGNATURE COUVIES THE FOLLOWING '1 CERTIFY THAT IN THE PEWV R MANCE OF THE Wont FOR WHICH THIS PERMIT IB ISSUED 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORK MAWO COMPENSATION LAWS OF CALIFORNUL' CONTRACTOR S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOW WG '1 CERTIFY TH T INTIN!PERFORMANCE OF THE WORK FOR WHICH TWO PERMIT IS ISSMO 1 SHALL EMPLOY PERSONS SUBJECT TO VIORN MAN S COMPENSATION LAWS OF CALTFORMAaTM;^PPUgCff LL UM M ADVANCE FOR ALL REOUIRD?1NSKCTM..AT t20t1 4/gJ��12s C/O/MSF/t7ETE DRAWING AT LOWER AREA PROVIDED elpnad x TRIP, / Dtea a PLOT RAN Or"to 900W 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM OR 1'IWP0SEO 2 OUTLINE OF THE PROPERTY WV1MG pMENSIDNS AND NORTH OBECTIOH EXPANSION OF SEWAGE DISPOSAL SYSTEMS 3 DIMENSIONED OU LINFS AND LOCATION OF ALL EXISTING AND PROPOSED t LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT STRUCTURES INCLUDING COVERED AVE"SUCH AS PATIOS,DRIVEWAYS MID WALKS. ON THE IVIOFERTY OR ADJOINING PROPERTY s L F—� DEPARTMBIT USS DIM1T Dom. Mw y� / Appte*Man Aaaapted B, O.wl b.p..11sh B, D.t. Pom 6.paatlan B!' Data Ow.lwedan Irrpw kmB, Data S Cainr..e..It ACCOUNTMO ONLY AID/ FAGS pt CODES FEE INFO AMOUNT REMITTED CHECKI)CMN RIMEWED BY DATE PEIIYITISFRVICE REGUEBT NUMBER INVOICE Pub Health Sery -Ermiro 173(1 AM