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APPLICATION FOR WELLIPUMP PERMIT ;AN JOAQUIN COUNTY PUBLIC HEALTH SERVICII i 1v. ENVIRONMENTAL HEALTH DIVISION P,0, BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA VMi,388 (209) 468.3420 EFUN61C9L EitMIT €XPIRES f YEAR F_DATE ISSUED TIComp6to ID Trip#Ir*t*► OPIA-1 DE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOn INSTALL THE WORK DESCRIBED.THISE MAL WtrH SAN APPLICATION IS ER Y CES EN' Of ALTH OtVISION. JOAQUIN COU DEVELOPMENT TRLE.CHAPTER 9-1 115.3 AND THE STANOAROS OF SAN JOAQUIN COUNTY PUBL((IICCrrHEEALTH SERVI JOB ADDRESSMA APN! d Z I 7 --]1 _ CITY 1�4P" PARCEL StZEIAPNR D ?6 1 7 z aC OWNER'S NAME ^rAna.v aM.rt� L/(�.. T /' ADDRESS S�rAl. 't 'G �i-P`Ic. ' Y0 PHONE r f6-7 3z CONTRACTOR Q I t�TEC_ L ___ _- ADDAISS I.• VC, 1� LICr�IO�7�� PHONE I�IIa a r7ZCsZ- OUR CONTRACTOR ADDRESS UC# PHONE TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑TMONITORING WELL a ❑ OTHER `-- ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CnO43-CONNECY REPAIR ❑ VAPOR EXTRACTION WELL E—_ J I ❑New❑Remelt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 HYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ OEOPLLVSICAI.WELL I � 80tL 80RING,.--. ef'f• -_ B ❑DESTRUCTION: INTENDED US E TYPE DF WELL CONSTRUCTION SPECIFICATIONS � A 1 l ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION el DIA.OF CONDUCTOR CASING D I ❑ DOMESTIC/PREVATE ❑GRAVEL PACKISIZE TYPE OF CARINGI5TFE1./PVC DIA,OF WFLL CASING D ❑ FUBUCIMUNICIPAL p❑�DRIVEN'F'y-c. I DEPTH OF GROUT SEAL SPECIFICATION K ❑ IRRIOA71OWAG K7 OTHER 5•'T bo),1 A, GROUT SEAL-INSTALLED BY �cl.�`�'F•�-G� f M- GROUT BRAND HAME 40 I e i- jEIN. ❑ MOINTOntNG GROUT-SEAL PUMPED: ©Yee [IN. CONCRETE PEDESTAL BY DRILLER:11EI Na S ! � I I APPMX.DEPTH (� — ZO - - LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CON*TRUCTIONIDIMLUNQ METHOD; MUD ROTARY AIR ROTARY AUGER� CABLE OTHER 1 HE9E8Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO REGULATIONS OF TILE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 71416 PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTAACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT 1N TILE PERFORMANCE OF THE WORK Pon WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPUC NT MUST CALL 24 HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTION*AT f2001480'"22. COMPLETE DRAWING AT LOWER AREA PROVIDED. �y 81*ned X 1 , T1t1e `f Af c. a,ci 1 Ct,,,'7 hJ 7L --- - De (�C? PLOT PLAN(Drew.to Seidel Raffle to USE BEWAG F H OOE.DIBI�8AL BY8TEM On PROPOSED 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATIONr•+. � 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYBTEMS. R� 3, DIMENSIONED OUTLINES AHD LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WFTHIN RADIUS OF ONE HUNDRED FIFTY FT. !� STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. - ON THE PROPERTY OR ADJOINING PROPERTY. . S �- La _' Irl - o, j•I 1� 'r .. '' � ' - - ,��ja�jydy/ .yco�' � C,� �, ti+9 Tru q ri rod •Z 3.j `/ F0 .o l.-4 ka. 42' QQ ..,.,.. ..... V.. ... -GZL o c` �^ 'aw`.., c•) ?'`: :oat /L� �r } 3rd fyW XT 2'31'35'E ` N,32 r �'D N N Qrq . � �- DEPARTMENT USE ONLY Ar ,.=w=-ApPlleerien-Aeeepted-By"�^". - "�", Gre.n lmpeellen By 'w Oate Pump Inmp-tlen By Date Oeedreaien tnrpeeilosi By=_ Des Cemmerlte: _3- j (42 ACCOUNTING ONLY: AIDR FACd PE CODES FEE INFO AMOUNT REMIT? CHECK CA8H RECEIVED BY DATE PEfiMITISUMCE REQUEST NUMBER INVOICE c5 �1 q Pub.Health Serv.-Enviro.173(3198) R • r