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APPLICATION FOR WELLIPUMP PERMIT �I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ✓� ENVIRONMENTAL HEALTH DIVISION J P 0 BOX 398, 446 N. SAN JOAQUIN ST„ STOCKTON,CA 96201.388 12081 498-3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fr4M*"i.T14Unb1 APPUCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMTT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRISEb.THIS APPLICATION IS MADE IH COMF4JANCE vwrk SAN JOAQUIN COUNTI'DEVEWPF//,Mr TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN CO.{U/'NJ7y PVBLICTHEALTH SERVICES•ENVIRONMENTAL HEALTH DIVISPJN JOB ADOREss/OR APN �b O�jU� n� y, �•- CIIITY//`K-�t��7�w(T-1�; P�ARCEL SIZEJAPNf_ OWNER'S NAME 'n nV`^�J• �L�o I+/� 1 ADDRESS-C b/.O dl /LaZw/ezl�P4 CONTRACTOR {-J,FX�C,et ADOREss-(p�6 �'a-IC ,yc�[.� LLCE/6137.3 _F11DNE//LG-96 J,f"" SVS CONTRACTOR ADORERS LICF PHONE F TYPE OF WELLIPUMP: ❑ NEW WiU 11 REPLACEMENT WELL ❑ MONITORING WELL• ❑OTHER ❑INSTALLA-i ION Ls WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPVR EATw.moN NWELL a q,p ❑N—Qlr H.P-�� DEPTH RUMP SET FT. FIRST WATER IFVEL O (TYPE OF PUMPI Was-At ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL 0 Cl SOIL BO'SNG S INTENDED USE TYPE OF WELL CON4TRIJCTON 4PECFGCATIONA A LrINDUSTRIAL ❑OPEN BOTTOM INA OF WELL EXCAVATION OIA,OF CONDUCTOR CASING D ❑DOMESTICIPRIVATE ❑GRAVEL PAC.IMN_ TYPE OF CAMMOISTEELNVC D;A.OF WELL CASINO D ❑PURLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION q ❑IRRIGATION/AC ❑OTHER GROUT SEAL INSTALLED BY GROUT SRANO NAME E ❑MONITORING GROUT SEAL PUMPED!❑Yr ❑N. CONCRETE PEDESTAL SY DRILLER:❑Y- [IN. S A►PRDx.o1T/TH dU/ LOCXN40 CHESTER BGXIBTOVE PIPE_ 5 PROPOSED CONETRLICTIONA MLUNG METHOD: MUOROTARY NR RDTARY AUGER _CABLE OTHER x, 1 HE"Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE VRTH SAN JOAQUW COUNTY ORDINANCES,STATE LAWS,AND FWUB ANO REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICEN 6�-O AGENT'S SIGNATURE CERTIFLES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR VASCH o THIS PERAIR 16 ISSUED,1 SHALL NOT EMPLOY PERGONS SUBJECT TO WOMU M'E COPAPE44ATION LAWS OF CALIFfi1W1A-'CONTRACTOR'S/BRING OR SUBGONTAACT1NG SIGNATURE CFTTTIRES THE FOLLOWING; '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I:A4ALL EMPLOY PERSONS SUBJECT TO WOIBOAAN•S COMPENSATION LAWS OF CALIFORNIA' APPILCANT MUST CALL 24 HOLIRE IN ADVANCE FOR ALL NEOL!♦RED INSPECTIONS AT 12001 A*-3423.COMPLETE DRAY~AT LOWER AREA P1OV10ED. Z ROT PLAN Ibr. tv Sul.,Caw. 1. NATES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ` 3. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS ANO NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONEDOUTHNPS AND LOCATION OF ALL EXISHNG AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. 7t STRUCTURES.INCLUDING COVERED AREAS SUCH A6 PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOIWNO PROPERTY. .............. .... .... � ........... MAY 2...2...19g6._ . . V60C HEAL.,H SERVIOES _. ..... ............ L- DIVI$I(ih J DEPARTMENT USE ONLY r Appllo.tivn Auc.v1.N BY_ (3,00 Ir P.vtlom BY_ Dw. Pvnv Irop.cLon BY E 9 Drtrtrvtbn In.p..[laO By D.. F►�G con,rn.nt.: 8/Is�IG-3L..E✓�ftlL Q/T.-Ad• ...��.�E L.t�� o 1�..LEJ�ls.�-/i.f.�� l°�[<..�..• [.ate.�o �cu �'{74--�I weQc.�� )Oirvt SRGcnt 4.F�..f B oyt -COUNS IND O Y. A1W FAC. PE CJDFA AMOUNT 116MTTED !CNH REcqkeC SY DATE ►BWII It'lls TCE IEEGUEPT NIfmGIl INVOYCf 7 t�10l I