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? APPLICATION FOR WELLIPUMP PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' MENT P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 88 E (2091468-3420 9 1""-r QF NdN•REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED {CompMte In Triplinto} fib'?' 1 ':••t ) LLS�I �+ Kl3NIS H B11'II(AAD£i0•�IILE!�ATI JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.T1418 APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOURTG�6'1Mr`� bECpFM� if O�IQOkER 9-111 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEiMCEB•ENVIRONMENTAL HEALTH DIVISION. JOB ADORESS/OR APN �G I _/��SSC/S r✓ _IJ rJ L� CRY�} -1IClrH PARCEL SIZEIAPNf�� OWNER'S NAME pQiV1 L' L- .ADDRESS Elt3�&214 097 Ste'O 4)2- PHONE 0 �4�9 coNTRACTORSmc-4 u M Ov)'•110 n 4 f..yr ty--, _ ADDRESS- PHDN£i SUS CONTRACTOfl ADDRESS LICK PHONE i TYPE OF WELLMVMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL i ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL If J ❑Naw❑Rap.lr H.P. DEPTH PUMP SET FT. RRST WATER LEVEL G IfYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL f ❑ BOIL BORNG S •. DE9TRUCTION:_3 "Z 2 W id ay)t�(7 !-- W'Caivj= -z INTENDED USE TYPE OF WELL CONSTRUCTION SPECIRCATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTICIPRIVATf ❑GRAVEL PACKISIZE TYPE OF CASINOISTEELIPVC DIA.OF WELL CASING D ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIDATIONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONIromo GROUT SEAL PUMPED: ❑Ya. [IN. CONCRETE PEDESTAL BY DRILLER:❑Y. ❑Ne S APPROX.DEPT N 'LOCKING CHESTER 9OXIGTOVE RIPE 8 . PROPOSED CONtTRUCTIORMNLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER - I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOME IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AMC , REGULATIONS Of THE SAN JOAQUIN COUNTY. 140ME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHtCI- Tl.us PERMIT IS ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'4 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIONATURE CERTIFIE€ THE FOLLOWING: CERTIFY AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CAUFORNIA I MUST M NOUR4 IN ADVANCE FOR ALL REQUIRED I PECTIONS AT 1200 4404422. COMPLETE DRAWING AT LOWER AREA PRDVIDED. .CU L f�� Slpned X + T1t1e ��`•'4 Oat. _ PLOT PLAN!Draw to 6"01Baaia 'to 1. NAME OF ETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE OISM13AL SYSTEM OR PROPOSED 2. OUT E o THE PROPERTY,GMN13 DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE D19POSAL SYSTEMS. 3. DIME NEO OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALK9. ON THE PROPERTY OR ADJOINING PROPERTY. _ . ..:.. ..:... ..:.. ..:... .. i = i1 i i ..i.... .. .. .. .. .- .. .. .. .. .-- ......... .. - : : - - .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ... .........:.....�.i.,...i.....i. .. j. ..�.. ., 'p, .... ..: . ...... ...., .. .. .. .. .............. _ - ...,.. .. .. .. .. .. . L M► ` :.......>. . :.....................:..........:............:........... .. .. ..:. ..:. ..::.. ..:.. . ...::..................._.. ........... ..:.. ..:.. . . ...........:.......:.......:................... ......<. �. . Grout Impaction STMT�� bate Lr I V r r7>r•Puna Impeetlon BY Dots Oeetructloo Impeatlon BY Date Comment,: ACCOUNTINO ONLY: AIDS FACE 3 v z f PE COpFJ1- FEE INFO{w9 .!MOUNT REMITTEDCHECKNICASH RECBVED BY DATE raj I-PBIMITISERVICE REQUEST NUMA�1 INVOICE �i ;'i.rr.-'. _ >�..iZ-?1lr�'iLI. •� i:. _.�_.�' ,./._G�'.. u ��.�..�s,.a.r__:/�4 _ ,_.�_��