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} � APPLICATION FOR WELUPUMP PERMIT cc -T SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 T WEBER AVENUE, STOCKTON, CA 95202 Pk+c,r � (209)458-3420 �� ✓ f n A IREB R RDlA DATE ISSUED COP ICempl/t,lot Trlplieu,I FILE APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WrTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1116.3 ANDTTHIE STANDARDS OP BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH D1VIStow JOB ADOREBB/OR APNI ?- v' - a S - 0 Z.1 /J r�L> Zo 0J ADL crTY rlf-^G PARCEL SIIEIAPN/ ti.. y o !�•c� 5 h/— OWNER'S NAME K- //V{/` L 41 0/1-1 S r�L . ��/, `�_ ADDRESS ` .n I^I`�M:,HfJ?vT Y1IyS_._ �' 'hrPHONE El / J.,_,,,,7c .•.pj!/p ,�.��-�C/�JJ`U rp,S CONTRACTOR 13ry /L L•ISIo [�-yq--/Ly�J�GI"jt/iC&J"L- AODRE88 S 7? l�10L-}PUSLI / C� PHONEP5tJ')9$9-ON Bus CONTRAOTOn I`✓L 0�v i�"J!�/L fl✓1•I L-c.l(••(•- _. .ADDRESS V I---'` 'ta-A LIC. G 3 3 5�y PHONE lr o GGs. ❑ NEW WELL 0 REPLACEMENT WELL ❑ MONITORING WELL S ❑ OTHER ❑ INSTALLATION I] WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑New❑Repelr H.P, DEPTH RUMP SET FT. FIRST WATER LEVEL O . pYPI OF PLIMFP ❑ OLTT•OF•SERVICE WELL ❑ GEOPHYSICAL WELL S US! BOIL BOfYNO i-�'/�/GJ7�1}�!(nLl�•- 8 D 0E$TRUCTIONI / ' �� J.O CONSTRUCTIONi C1 IC ONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ' O DOMEETIC,PISVATE ❑ORAVEL PACKINI;E TYPE OF CASINGU8TEELlPVC DW OF WELL CASINO D ❑ RIBLICIMUNICtPAL ❑t)MVEN DEPTH OF GROUT BEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ❑,MONITORING GROUT SEAL PUMPED: ❑Yr ❑NO CONCRETE PEDESTAL BY DRKL.ER:❑Y. ©Ne 5 i� Approx.QVTN—„ h'i i4 x 10 I LOCKING CHESTER BOXISTOVE PIPE S j PROPOSED OON$TRUOTIONMRILIING METHODr MUD ROTARY AIR ROTARY AUGER CABLE OTHER I WOW CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,!SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-8 COMPENSATION LAWS OF CALIFORMA.- CONTRACTOR'S HIRING OR SU"ONTRACTMIO SIGNATURE CERTIFIES THE FOLLONMN01 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUSJECT TO WORKMAN'S COMPENSATION LAWS OF CALMOF NIA.' TILE A OANT M 24 HOURS IN ADVANCE FOR ALL REQUIMID INSPECTION*AT 12"14004422. COMPLETE DRAWING AT LOWER AREA PROVIDED, SIenN x ,�� This I C.17 1=/L/U7 J•:/L n.,. I / 1", ��! /. PLOT PLAN Mtow t.Seelel SOOIS�.•to I Z� i I. NAME$OF EYELETS OR ROADS NEAREST TO OR IOUNDINO THE PROPERTY. t. LOCATION OF ROUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED E. OUTLINE OF THE PROPERTY,GIVING WMENSIONB AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. DIMENSIONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. 11TRUCTUR10,INCLUDING COVERED.AREA$OWN AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, \ 16 � s X44 /�'rJyyy ,K'J' \+• �[ . ovt-c>vc. o L�ri7u e, V u_.. . • _ {/�/ �_-��•—� .ra qui a+,luMt:.trse:aTTl�"�_ � �?Q _-- AppIISSlIen ASerpled BY - �` `\ Di1i ! , I. ls0 InlpSellen 8F DDI+ Pump hrp.nllnn SY Veto 1M11N1s1"spoellen 0 Dolefs,10�[9 S,-r6 v15rr �RcZ;rE�G (FLEC[SILLIA41 ro- !rtRcAGGErzC_r..;,g) k& MR._!17 zz"ew WS/,`/ vT&vjL4j: 7a aAr T -No rd e 4 ONtYI AIDS FACE �7k/RTr:R �IU+Salt I, 8 ar��9 vim two AMOUNT REMITTED ECH C !CASH RICIRWO EY O E PERMITISEAVICE RVO EOUEST NUM81E1 INVOICE � oa