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l�LICATION FOR WELL/PUMP PERMIT SAN J, UIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE",STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMfT EXPIRES f YEAR FROM DATE ISSUED E ICampl.ts M Tr�Reu/M APPIICATbN IB HERE S'.."O TO THE SAN JOAQUIN COUNTY FOR A PERMIT i0 CONSTRUCT AND/OR INSTALL THE WOR'btSCMUTD.TISa APPLICATION IS MAGE IN COMPLIANCE WITH BAN JOAOUIN COUNTY UEVELOPMENT TRIS,CHAPTER 9-1116,3 AND THE STANDARDS OF BAN JOAOUIH COUNTY PUBLIC HEALTH SERVICES,EWFIDNMENTAL HEALTH DIV OWN. JGR AODRE98/GR APR/ FF f / CITY _ rt I c�F_� Lac-�PAFICEI BQE/ApN/ OWNEn'e NAME �j^1 1�.-_//.��^ V�Y5_S ADDRESS .5-6/,_�_/. L)(J/`��_ S�� PeoHE/ CONTRACTOR Fp' ."j""T-S �4-t,.- I_ ADDRESS�O 08O/t I h 'ec, /y53 ip, PHONE/ �y BUB CONTRACTOR AbDRESS uc, � PHONE rJ TYPE OF W110"MPI ❑NEW W[LL Q REPLACEMENT WELL ❑MONNONNO WELL• 13 OTHER 5 ! ❑INSTALLATION Q WELL SYSTEM REPAIR Q CROS9CGNHECT REPAIR LJy VALOR EXTRACTION WELL/ J ✓[ �❑Nry❑R.vdr H.P,-��L bfMN R1MP SET FT. FIRST WATER LEVEL PE O nYDF WMP .�r4c�'mr+z.l` I-y ❑OUT-OFSEAVICE WELL Q OEOPIIYSICAL WELL f ❑ SOIL SOfnNO S j LDESTRUCTN)1t. t'� INTENDED USE TYPE OF WELL CONXTRUCTPON$PLCIFLCAHOPHI q V EE^^ �❑OMUJ.T PIAL Q OPEN BOTTOM OIA.OF WELL EXCAVATION DrA,OF COHOUCTOR CARING O L.Y'D ItHCIPRIVATE ❑GRAVEL PACIVSIZE TYPEOFCASWWIHEELRVC DIA,OF WELL CASINO - O 11PRLICRMUMCIPAL ❑bRIVEN DEPTH OF GROUT SEAL SPECIFICATION F C ' ❑inROKHONIAO ❑OTHER GROUT DEAL INSTALLED BY r T GROUT BRAND NAME E ❑MON170RNG ORDVT DEAL PUMPED:oy- ON. CONCRETEPEDESTALBYDRAEER:❑Y. ❑Ne s I� Avrnb k.bEF'IH LOCRUp CHESTER BO%IBTOVE PPE 5 0. PIOPOSED CONSTRUCTIONIDRLUNG METHOD; MUD ROTARY AIR ADTMY AUGER CABLE OTHER I HE9EDY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAOMN COUNTY OMANANCEB,STATE LAWS.AND RULED AHO REGVLATIONS OF THE SAN.JOAOUIN COUNTY,ROME OWNER OR LICENSED A..'..1.11 TURE CERTIFIES TICE FOLLOWIHO:-1 CERTIFY THAT M THE PERFORMANCE OF THE WOIR FOR YNIICH THIS PERMIT 19 ISSUED,I9HALL NOT EMPLOY PEAOGN8 BUBJECT TD WORKMAN'S CGMPENiATION LAWS OF CALIFORNIA,•CONTRACTOR'B HTRNG Oft SUBCON7RACTINO GONATURE CERTIFIES TNT FOLLOWING: 'I CERTIFY THAT IN TIIE PERFORMANCE OF THE WOR'FOR WHICH THIS PERMIT It ISSUED,1 SHALL EMPLOY PERSONS BVBJECT TO WORKMAN'S COMPENSATION LAWS OF 1 CALIFORNIA T PfYIC 7 MVi7 CA ]1 HO VqS IN AGOING[FOR ALL AFOLMIED IN/EEG NS AT[IDPH�HJd]s.CO E ONWARD AT LOWER AREA PROVIDED. 1 # 9rg—, AA/1 Tn. N flJl T� PLOT PLAN 0-1+0ed.1116.1. 'le ].NAMES OF STMET6 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF NOOSE SEWAGE DISPOSAL SYSTEM OO IMPOSED 2.OUTLNE OF THE P10PERTY,GATING DIMEN8ION8 AND NORTH DIRECTION, EXPAIIDKIN OF SEWAGE DISPOSAL BYSTE149. ' 3.DIMENSIONED OVRINF.B AND LOCATION OF ALL EXISTINO ANTI PROPOSED S.LOCATION OF WT"Yr1THIN RADIOS OF ONE HVNDIFO FS FT. - STRUCTURED.INCLUDING COVERED AME-At SLMH AD FATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ..... ............. ......... .......... . .......... . ........Z -J....... .. ...... ....... ......L ........... ...... ............ ...... ............ .......... ...... .... ...... .... ... ... ... ... ._.___. . T-................. ..... .... . ........ .................... ....... ... .......... iI ....... .............................v.. . ... ..... ...... ... ._._ ............... ...................... ......... .................... ........... .. ............. ..... ....................... ..... ............ ......... ............ ..... .............. .......... ................. ...................... ...... .......... . .:. ..,,, .,,.. .... .. .. ..... sail JOAoulN County..., PUaLIG HFI,LTH SERVICES I OFPARTMFNT U1[ONLY �P'�''iii AFPSawOm A.eq,sd BY Ort• Me.�i..�.��I � dmn k-."—By a,.en�ns...er..P..au�Br DN• I ACCOUNTING ONLY: AFD/ FACT Y DECODE. FEEIHFO AMOUNT RO'ATTEO CHEC PLANT RECEIVED BY DATE PERMITISETIVICE REQUEST NUMBER INVOICE iLl 83L6 ILI!m b PUb.Health Sew.-ENYira.173 11197)