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,Lrf� APPLICATION FOR WELLIPUMP PERMIT �! SAN JOAOUIN COUNTY PUBLIC HEALTH SERVrar S PAYMENT ENVIRONMENTAL HEALTH DIVISION PECE�VED P.O. BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 95201-. .L/' (209) 469.3420 A{>� 0 1 1°'F �Ywr SAN ::. U 1, , ';I 'r � /� NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM GATE ISSUED PUBLIC h:i.r`. I ' '• I •i ll'r-S {HES (Complete In TLpIkEtEI ENVIROWLN. ._:':c, •`;:i;JISiON APPLICATON IB HERE BY MADE TO BAN JO N C O PEIIMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY,�DDEEV��ELOPMENT TITLE,CHAPTER 8-11 .3 ANJO-THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH MVISION. JOB ADDREB8,Og11P41 — 35 141 -k)-.. LG Iy L,7�Aj. _CITY rc/�C�_ s- I !� PARCEL BI2E/APNI OWNER'BNAME JA:✓"IES /"IL��c-,r) (7„N„1Y/L• CAVILiC,�4ADDREBS L'.0.0� Zt� ��y c✓L // 1 x j TC77[J-az97 ProHEC1Oq) �35 AbiL CONTRACTOR -r 11dAWFr'TWL.i -t;' A E �— -47`'N ADORERS :aro SJnJ wcsYp'.nc.C�Sf�.'�'�CE PHONE��•I- -�SUR CONTRACTOn N 1 v. �kF-JQL�Ok11i.S "f--L NrY.��F<-E�.T.r SJs F'-nET✓73 ADOn15Re zL1—L-.IoL.Srcv r.... ucF PHONE 0 7 I TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL F ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR088 CONNECT REPAIR ❑ VAPOR EXTRACTION WELL P 'L l IT VPE OF PUMP) ❑N—❑P,.1, H P. DEPTH PUMP SET FTFI . RST WATER LEVEL p{ ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLE BON.BORING B� ❑DESTRUCTION: / [` R INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION CIA.OF CONDUCTOR CARING p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/81215 TYPE OF CASNKU TEELJPVC DIA.OF WELL CASINO pZ ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GFOUT REAL C: a' - PEi7PA SPECIFICATION - R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY OROVT STAND NAME s//4I G78YCV7E E 11MONITORING 7 //�P�r LITHSI 4 -/ GROUTSEALPIMPED: ❑Yr [IN. CONCRETEPEDEWALSVd R:❑Vw ❑Ne 5 N APPOOK.DFPTH�(J I �fr I I ^, 11 I LOCKING CHESTER SOX/BTOVE RPE Byyy PROPOSED CORMUCTONGMEWNG METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER p I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOM WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AN REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S BIONATURE CERTIFIES THE FOLLOWINO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR LIC M THIS PERS IS ISSUED,I MALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR M"ONTRACTING SIGNATURE CERTIFIEA�OO THE FOLLOWING: .1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFOR�A.' THE MUST Ci IM ADVANCE FOR ALL REQUIRED TKINS T p.1Stf. COMPETE DRAWING AT LOWERAMA ��0� elae.e x U• / ntl. 77 Av MOT PUN to,.Ur SoO.1 SP.1. •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF MOUSE SEWAGE DISPOSAL SYSTEM OR PmrQMD 2. OUTLINE OF THE PROPERTY,GING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DIBFOBAL BYSTFuS. 2. DIMENSIONED OUTIJNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 14� . �' \ I \�/vn ED •W —eePARTxrTIT USE GNLY nppllcnlan A..,1-1 BY -- ! D.Sm I A,. Gm1X I wP«non By D.I. Pump Inepwtlen By 0.1. Dslructlen ImpeeUen BV dl. Commenlr NO Uwe JMO E'UBl IL.HE4f.i u :•E{;u�I;,- ACCOUNTING ONLY: AID) FACE PE CODFJ FEE INFO AMOUNT REMITTED CHECKS ASH RECEIVED BY DATE PERMIT/SEANCE REQUEST NURSER INVOICE v I� 67 3 ?, ± 1 r