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�Om APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTS'PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,44S N.SAN JOAQUIN ST,STOCKTON,CA 96201.388 12091460-3420 ND4PEfUNOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED/J�/`/ Mwpfea IF TTIpIkFa? APPLICATION IS HERE BY MADE TO THE SAN JOACUIN COUNTY FOR A PERMIT TO CONSTRUCT AND,OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE N(:'I NCF WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHHAPTER�S--111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DNISION. I JOB App{ESB,OR APR/ /�9 F {--�/"•rr /E DQ� Odt��CITTYY '4t w�t'w o PARCEL SIZEJAPNs OWNER'S NAME Y l J/M q �Q..7(p,✓�r ADDRESS ODNTRACTGN //A/'/F'r J/ra��I✓ ADDRESS [ REWC. PHONE. SUS CONTRACTOIt ADDRESS UC. BONE s TYPE OF WEWRIMP. ❑NEW WT31 ❑REPLACEMENT WELL ❑MONITONNO Wf11• ❑OTNEA C3 INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSOONNECT REPAIR ❑VAPOR EXTRACTION WEL'• J Cl N—❑Fe Wl H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL 0 (TYPE OF PUMPIB ❑OUT-0E-SEfMCE WELL ❑GEOPHYSICAL WELLSso*- ❑DESTRUCTION- 1 NTMOED WILL CONSTRUCTION N'ECIFICATIONS C A ❑INDUSTIEAL ElOPEN BOTTOM UUL OF WELL EXCAVAT ON DIA.OF CONDUCTOR CAGING O ❑DOMESTlICB'RIVATE ❑ORAVEL PACKRSRE TYPE OF CASINGISTEWFVC DU.OF WELL CASING D ❑PUBUCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SKCIFN:ATIDN R ❑INSOATOWAG ❑OTHER GROUT SEAL INSTALLED BY SPOUT BRAND NAME— [I AME❑MONITORING GROUT SEAL PUMPED:❑Ys ❑N. CONCRETE PEDESTAL BY DPoLLFA:❑Y. ❑W S I AAPROX 00"N LOCKING CHESTER BOXWrOVE RPE 8 FROPOSM CONFTRUCTONAR ILUM METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PRE4ARF.D THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENTRFO 'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERMANCE OF THE WORK FDR WHICH THIS PERMIT IS HUED,I WALL NOT EMPLOY PERSONS SUBJECT TO WORNMAN'S COMP04SATWN LAWS OF CALIFORNIA:CONTRACTOR'S NINNO OR SUBCDNTRALTING SNVUTURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT N THE PERFORMANCE OF THE WON(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOMI M IWS COAMOIEATWN LAWS OF CALIFOftlJIA.'THF APPLICANT MUST CALL 26 NODU IN ADVANCE FOIL ALL IE,QURED INgpoaTWNF AT 42"14"4422.COMPLETE DRAWING AT LOWER MEA PROVIDED. Ba—I T KAN IDm,m SwNO 6aW� <°�JGiL q:• 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE$HVAOE DISPOSAL SYSTEM OR PROPOSED •.T 2.OUTUI E OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWMIE DISPOSAL SYSTEMS. , J.DWSNUONM oWRUNFJT AND LOCATION OF ALL EXISTING AND PRPO OSED F.LOCATION OF WELLS VVffHN RADIUS Of ONE HUNDRED FFTY FT. R- STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK$. ONTHE PROPERTY OR AOJONING PROPERTY. \4 ....'. ...I. .. .. .. .. b I .. . i kr a o v. ..... .......<.... f u cr ?ril " 1. ` Y V '. VW. s i r,... ..........:......� ..,• a ..... ... .................p..�I .9�,. ,...�3.p•...;...,.;....;.... . . ...e ..... ....;.. n L :.... ... ... ` i r a•• A ..... ✓.. ` ......._i •... L DEPAFrT/MEWr WE ONLY 1: .^Appllutbn Ac—.d BV Dme�� Mei _{'•.. ,t .�� .a'r '='DaN'P� '�''T'1rn0 livPig(en Bti 5A' y—` �g—'°cw=.Sq�1CCI•rv�"alb�R"BY r:-, D•ia D�vuollen E'nPmT1�o BY (} ,� � ryl S--p-t- R CCt� IYS—Ct4L-3a-. I AGCOUNTMI0 ONLY: MDs FAG PE CODES FEE INFO AMOUNT RI MTTED CHfOF1RCASN RFLBVFD BY DATE PE MIT18—CE REOMT NUMBER INVOICE 01 LAO