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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 FILE (209) 468-3420 Co NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p y ICampht@ In Tirlpff atal APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMn INSTALL THE WORK DESCRIBED.THIS APPVCATroH 18 MADE IN COMPLIANCE WITH SAN JOAOUtN COUNTY DEVELOPMENT TITLE,CHAP�TryE/Rf 9-11x115.3 AND THE STANDARDS OP SAN JOAOUIN COUNTY PURLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMepN, JOB ADDREBSMR APNI`1�f1 I 1- P i`4 1 f 1�+ ■�dJ - _ _ CITY � JDA I/'' [^ PARCEL SIZVAPNI �o A CI OWNER'B NAME �0 v 1` �Kk�I LC Y ___ __ __ ADDRESS 'R N Y A Lis PHONE I�% 7-s r� CONTRACTOR_- �`I !g C�`LC7SS _- ADDRESSeO YelO nr __-. UC/ ^J�_P{IONE/ Z2 - L Y SUB CONTRACTOR ADDIIESB Llcp PHONE• TYPE OF WEI�UMW,1<HEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL l..: ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CHOS"ONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ;I!1Rraw❑Repak H.P. _ ; DEPTH PUMP SET FT, FIRST WATER LEVEL O (TYPE OF RV MPI ❑ OLrTBF•BERVICE WELL ❑ GEOPHYSICAL WELL d ❑ SOIL BORING B ❑WSTRUCTIONt INTENDED USE TYPE OF.WELL CONSTRUCTION SPECIFICATIONS A `,❑ INDUSTRIAL ❑OPEN BOTTOM ORA.OF WELL EXCAVATION I l DIA.OF CONDUCTOR CASINO a �C J DOMESTIC/PRIVATE AGRAVEt PACKISUE TYPE OF CASINGISTEEIJPVtC CVC 0' DIA.OF WELL CASINO D ❑ PUSUCIMUNICK AL ❑DRIVEN DEPTH Of GROUT SEAL L n l7 �+ ____ __ SPECIFICATION R HL ❑ IRRATIONJAG ❑OTHER GROUT BEAL INSTALLED BY C-61` I CLONE GROUT RRAND NAME CEfh t�--t E ❑ MONITORING GROUT SEAL PUMPED:JgVm ❑Na CONCRETE PEDESTAL BY DR ILLERt-i�Ym 0 Na 9 APPROX.DEPTH LOCKING CHESTER BOXISTOVE POPE S PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9EBY CERTIFY THAT 1 RAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE NRTH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REOULATIONS OF THE SAN JOAOUtN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I 6I4ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'@ HIRING OR RUB-CONTRNCTWO 810NATURE CERUPIES THE FOLLOWING: 'I CERTIFY THAT M THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMVT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOVIVAAW8 COMPENSATION LAWS OF CALIFORNIA.-TTHE AAPPpJL/rANT MUST CALL.24"OURS IN ADVANCE FOR ALL REOUn1ED INSPECTION!AT 12061 40*-1!427, COMPETE DRAWING AT LOWER AREA PROVIDED, - @Wad X 1. . JC7C J'7A.`-t+-. _ -- TitM f)L.i 011e - Geta �Z` PLOT PLAN Maw to Seelei Beale •to 1, NAMER OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PRORrtRTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OVTUNE OF THE PROPERTY,Of VINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEM@. 3, MMENBONEO OUTLINES AND LOCATION OF ALL EXrSTIFIt AND PROPOSED S. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT, STRUCTURES,INCLUm"O COVERED AREAS SUCH AS PATIOS,ORIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOWING PROPERTY. : _.. Sa - _ _. � .. .. . .. MAR 2 . 9.99 .. ..', l r�J�4i "AIN.0AcJrF PU1�l f t I NVIH �A1 ?�':Al� is T i�. .®r. en - - . DEr T veE onLY. -� f /yfJ '.Appamiten Amepled By 1 :(,. L/7/' M!4 Mm G O,eul kwpeetbn BY ��-Y/' Q ��+-"*�=- D.ta p knPe.11on BY Data l r Oearmelen tmpeetlen BY Data canlmaM.• �� O'S-4• Kt -C) �.. ACCOVNTINO ONLY: AIDR FACT PE CODES FEE INTO AMOUNT REFATTEDC C ASH RECEIVED BYDA E PERIMIUSERV10E REQUEST NUMBER INVOICE k Pub Heafth Serv.-Enviro.173(1197)