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uu APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 � �'�//� (209) 468-3420�J, t,S FRA._ I NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CRmpiRtR In TTipOcm6) APPLICATION 18 NEPE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WON(DESCRIBED.TMS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TILE,CHAPTER 8-1115.7 AND THE STANDARDS OF 8A JOAQUIN COUN3 PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADOREBSAR AM' - - CRV '41 � PARCEL 913EIAMI OWNER'8 NAME ADDRESS •! F �Vne i COMRACTOR .. ADORERS � Ya. 6'MR 2J�RHONE I :'� BUB CONTRACTOR FfmaADDEIE88 UCI PHONE/ TYPE OF WELL MP: 2L NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER �"1 ////1 ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ✓ „J j'� �TN�.r❑RepJr N.P. DEPTH PUMP BEj2-4;27. FIRST WATERLEVF�� O TYPE OF PUMPI ❑ OVT-0E-SERVICE WELI ❑ AEOPHV6ICAL WELL/ ❑ SOIL BITING S ❑OESTRMHON' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIfICATION6 A ❑ INWSTRIAL 11 OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O KDOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE Of CASINO/STEEL/PVC DIA,OF WELL CASINO O ❑ POLILMUNIOIPAL ❑DRIVEN DEPII OF GROUT SEAL SPECIFICATION R ❑ ISRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY URDUT BRAND NAME E ❑ MONITORING '7 T GROUT SEAL PUMPED: Ely. ❑ ❑ Na CONCRETE PEDESTAL BY DRILLER:❑Y. NS 5 '32-5- ] - APPROX.DEPTH 7 O-S LOCKING CHESTER BOX/STOVE RPE 5 PIOPOSED CONtTRUCTIONRHNWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HERESY CERTIFY THAT I THAW PREPAREO THIS APYJCATION AND THAT THE WOM WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OPOINANCES.STATE LAWS,AND RULES AND - REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR MERGED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WoM fon WHICH THIS PHRASE IS ISSUED.I BNALL NOT EMPLOY PERSONS SUBJECT TO WOARMAN'I COMPENSAMN LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUS<ONTRACTIIG BIO TUPE CERTIFIER THE FOLLOWING: -I CERTIFY THAT m THE PERFG ANCE OF"T/ WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WOIIBMAN't COM RATION LAWS OF C��ORMA.- TbGAP"ANT MUST CALL 24 I IN AM 9 FOR ALL REOIURED INS)!)iC 141 T 130m AN-MI1. COMPLETE OMVANO AT LOWER DAMA PINI < ROT PLAN IDq—HB Saalal Raab 7,<l7 'IS 1. NAMES OF BtIIEETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR POIOSED i. OUTLINE OF THE PIIOPRTY.GIVNAI UTA HAMNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMS. O. DIMENSIONED OVTLINFB ANO LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUR OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATICDL DRIVEWAYS.AND WAMS. ON THE PROPERTY OR ADJOINING PROPERTY. / � r PAYMENT y I , U SEP 21999 ENVIRONMENTAL HEALTH UIV75VUI'd G I U Ofill"TMENT USE ONLY /i /.� /��• -� / `�l/��