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APPLICATION FOR WELLIPUMP PERMIT E `"W p -00 s I .tom e� m, - SAN JOAQUIN COUNTY PUBLIC HEALTH SERv.,.E-S ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA '"WAY 2 1999 (209) 4883420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED EWRCNMENTAL HEALTH (Complete In Triplktbl n:ERA/111T/SERVICI=c, APPLICATION IB HEM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOn INSTALL THE WON(DESCRIBED.Title APPLICATION 18 MADE IN COMPLIANfE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEA/LTH SERVICES,ENVIRONMENTAL HEALTH DMBION. JOB ADDRE98MA APN# J YAly MAR S P D(�w•�� CIT M201'/—f ) PARCEL SIZEIAM, OWJNER'S NAME LAI,)I ) -jR ADDRESS �5TMLS]7'f10NE �Y,1s COMPACTORVL� 1 1 111 1E{ ✓6'l2, CD 90Y39 _ �� ADDRESS? s� � y LIC/C�-��/LJ-I ATONE Aug CONTRACTOR V�(.�Ky ✓� ��(_yyxi ADDRESS J C]� L- • 1.- V �.. DCI y� n 1 1 TYPE OF WELLJPJMP: NEW WELL ❑ REPLACEMENT WELL WMONRORING WELL Im�,y/L�(/�R' ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR T ❑ VAPOR EXTRACTION WELL F ❑ ITVPE OF PUMP] TI—❑Reptlr N.P. OERTH NJMP BET ET, FIRST WATER LEVEL O ❑ OUT or SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL SOBMG R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF MLL EXCAVATION .CSC F✓ DIA.OF CONDUCTOR CASING Al/F O ❑ DOMESTIC"IVATE GRAVEL PACKIBIZE TYPE OF CASINGISTEFLIPVC_/y y DIA.OF WELL CASING L FY D ❑ PVBLICMUNICIPAL ❑DRIVEN DEPTH DF GROUTSEAL 3D'•{S / SPECIFICATION SrA/ R �❑ IIRRNOATKINIAG ❑OTHER GROUT SEAL INSTALLED BY JX J, GROUT BRAND NAME F p MONITDNNO GROUT DEAL PUMPED: C�YV. [IN. CONCRETE PEDESTAL BY DRILLER:❑Y— ON. 5 AApp.nx,AS"" I t T`) �� I LOCKING CHESTER BOX/BTOVE NFE g PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER 1 HMOY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WON(WALL BE DONE IN ACCORDANCE WITH CAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WNICI4 11419 PERMIT 1818SUEO,I SHALL NOT EMPLOY MRBONS SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA.' CONTRACTOR'8 HIRING OR BUS{ONTRACTING SIGNATURE CERTIFIES THE FOLLOW WO: 'I CERTIFY TINT PERFORMANCE OF THE WOM POR WHICH THIS PERMIT IB HBSVED,i SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPVHSATHON LAWS OF CALIFORNIA.- THE AN M STC 24 HOURS IN ADVANCE FOR pLL REQUIRED INSMIAONS AT 120814YJ122. COMM(TE OMWING AT LOWER AREA PROVIDED. Blo—I X (sQCF .�J{I Tin. '71,/7,✓ //`�i Y.f-7]'/�/�/ S% D.I. MOT PUN IDI...le B W.l BP.Ie to H. NAM OF STREET"OR ROADS NEAREST TO On BOUNDING THEPROPEIUW. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PMPOSED 2, DU`TL HE OF TNF PIIOPERTY.OMNO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIPPORAL"YOTEM9. (' J. DIMENSIONED OMUNFB AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN MOILS OF ONE HUNDRED FIFTY BTRUCTVRES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. QT,) mvJb C �V\Y1\ ' Abl't5.! IJP "fU SCALC C C, IA)fr COUtrJ0 /JCWI Tr � - lexlS}1� l,Lt�s i DEPARTMENT USE ONLY Avplle.nen AeeeplM 01 L D.M MSUHBr D.1 gh A /15Pw11" r4 / / 17� D.I. Br�� / c.�nmww.: ld,2e' E SGL — e 5 �S OGK.ct, 'r �YC /•++-C/d L ACCOUNTING ONLY: AID# FAG PE CODES FEE INFO AMOUNT REMITTED K CASA RECEIVED BY DATE PERMIT/tERNCE REOUEei NUMBER INVOICE Pub.Health Serv.-Enviro. 173(3/96)