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.r f APPLICATION FOR WELLIPUMP PERMIT SAN JOAIIUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION s P 0 BOX 389, 446 N.SAN JOAQUIN ST., STOCKTON,CA 95201.388 u (209)469.3420 ply MOM-REFUNOARLE PERMIT EXPIRfS i TEAR FROM DATE ISSUED f C ICnmplets in TTiplicaal APPLICATION IS HERE OY MADE TO THE CAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRVCT AND10R INSTALL THE WORK DESCRIBM.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUfN COUWTy OEVELOPMfNT T�R-Lf..CHAPTER 8-7115.3 AND THIF STANDARDS OF SAN JOAGU7N Ca DAFFY PUBLIC HE TH SERVICES.ENVRTONMENTAL HEALTH DMSION. ' JOB ADORESStOR APNI-EJ¢ r a/1/1 / `� CITY r�µ PARCEL SIMAPNA OWNERT NAME Rle LA •k— 1 ADDRESS 1 F1fONE CONTRACTOR 1 t A AOORE664R!a n.?G LICM PHONE I i SOB CONTRACTOR ADDRESS LIC♦ PHONE TYPE OF WELUPJMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL M ❑OTHER ❑INSTALLATION Cl WELL SYSTEM REPAIR I •(�'" ClCROSscONNFCT REPAIR ❑VAFVR EXTRACTION WELL I 0 J 11 OF PVIAPI N—VA-* H.P. DEPTH PIMP SEI�FT. FIRST WATER LEVEL G • O ❑OUT-OF.SERVICE WELL ❑OEopmrymcA WELL F Cl SOIL BORING a ❑DESTRUCTION- INTENDED LIAF TYPE OrWELL CONSTRUCTION SPKIHCA TION{ A INDUSTRIAL p❑ C3 OPEN BOTTOM OFA.OF WELL EXCAVATION OTA.OF CONDUCTOR CASINO p C Ey OOMESTICRRIVATE ❑GRAVEL PACK767IE TYPE OF CASINIMSTEEL'PVC DIA.OF WELL CASING D ~ ❑RIBUCfMVNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R (1,1 ❑IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑MONITORING GROUT SEAL PUMPED:❑Ys [IN. CONCEIETE FEOESTAL BY DRILLER:❑Yw [I," 3 APPROX.DEPTH_ f l � LOCKING cHESTER BOX1SCo m RPE a PROPDSM CONSTRVCTIONIOWL"NO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER G I HEREBY CERTIFY THAT I HAVE PIEPAREO THIS APPIICATICN AND THAT THE WOPK 1MLL 4E DONE K1 ACCORDANCE N/[TN SAN JDAONN COUNTY ORDINANCES,STATE LAWS,AND RULES AN r REGULATIONS OF THE SAN JOAOUIN CDUNTY. HOME OWNEq OR LICENSED AGENT'S SIGNATURE CERTIFU:S THE FOLLOWING:9 CERTIFY THATW THE PERFORNFANCE OF TME VMFIK FOR WHICH THIS PERMIT 15 MtUEC,I BHA"NOT EMPLOY PERSONS 6U§LKT TO W DRKMAWS COMPENSATION LAWS OF CAUFORNIA,-CONTRACTOR'S HIRING OR SUBCONTAAC:TINO SIGNATURE CERTIFIES THE FOLLOWING; •I CERTIFY THAT yINCTHE PEPFORMARCE OF THE WORT(FOR iMnCH THIS PERMfT IS ISSUED.1 SHALL EMPLOY PEREONB sUB.7ECT TO WORKMAN?COMPPSATION LAWS OF CALITSlCrW XN E APiLI C1W7 MUl bllli IN AWANCE TaR ALL REOiARFL KyY Ra A7 11M11WJeSJ.CONFLATE DpAWINO AT LOWER AREA PFpVN1f{/. Slened X ��YfGY-y✓/�// _«� TMP__ �I/'� RAT PLAN ID—to Seely DeAle r "t�`o 7. NAMES OF STREETS OR ROADS NEAREST TO OR BCVNMG THE PROPERTY e. LDCATIOH OF HOUSE SEWAGE 0fGPDSAL SYSTEM OA F71MpOBED Y. OUTURE OF THE PROPERTY,DIVING DIMENSIONS AND NORTH DIRECTION. EKPANBIOH of SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANO PNDP06ED 6,LOCATION OF WELLS WFTHA RADIUS OF ONE HUNDRED FIFTY FT. 1 s7RtIC7UAES.INCLUDING COVLREb AREAS SUCH AS PAMS,ORIVEWAYS,AND WALKS, ON THE PFIOPERTY OR ADJOI MN13 PIOPEREY. 1 tr � I 4 Ai f .:.. DEPARTMENT USE ONLY APPI�OeVon AceeptAy By 'I e Z' Me. i Grout Impeetlen By Is _ DAIS wnP IrvP.cnnn 5y I [IrttlLC[mn irspeetlon By Canmctn. I ACCpUNTNO OK LY: iI Al. I FACA I I PE cpaEB FEF INFO AAFOUNT qEI 117TID CNEC CASH RECEIVED BY DATE PD7MIT SFRWCE REOUFAT NtNNafll IHYOME Sv l z 5 ice' � SR gl�s _—