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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SER ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988,304 EAST WEBER AVENUE,STOCKTON, CA 9SWI-an I209I 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComploto In Triplicate) APPLICATION 18 HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE Ma SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116. U e,.13 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE@,ENWRONMENTAL HEALTH D ISIIONN. JOB ADDDESRMR AMR 6 o Wes+ Lodi A,aa-r1CITY 1 V od L. PARCEL BIZEIAPN#033-I l/� O 'J1 ��11�� CJ�.. {� L 13L+ o OWNER'S NAMEI'1'BIQYICQy1 Nw'es�9�II� Ie(+4S# 6N.L AOOREFS $at+ Lala C1"/, UT CA 111 PHONE 11901-961-5776 CONTRACTOR O Y NBTI1-OV\ 3�„S ADDRESS In. JEeL rA 44S9QsHu P+oNE#SIO'97$''347,j SUB CONTRACTOR TraW 661 (mwirvilme4ol dgmhemiSiY H(g' 13604 o&o 1y1,r Paris Place B V ��ADORF.aS �nWLIIO CvdOW.C�QC74.3 UC#706 PIIONE#/16—SS3-8010 TYPE OF WELVPUMP' ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J HYPE OF PUMP) 11N.11 B .I' N.P. DEPTH PUMP BET FT. FIRST WATER LEVEL 0❑ OUT-OESERVICE WELL ❑ GEOPHYSICAL WELL# FOIL BORING 45 SaI S VQMY$QWLQ R@ ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS '1 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION S'/I IJ INGh25 DIA.OF CONDUCTOR CAS'IN1000O�yyyy I CM4Z D ❑ DOMESTICIPRIVATE ❑GRAVEL PACKIBI1ZE TYP!OFCABINOIFTEELPVC1- A)OYI¢ DA.OFWELLCASING ISIC—O P IEAb D PUBLICIMU 11 EN ❑ I RIIOATIONIHAGP� XODTB ER soil V`a Y �'�QIL GROUT READEPTH OF L INBTAl1EDUT ��F1E� 8�S SPECIFICATION q p COILEGTO� US\.,�•ax BMW BRAND NAME ` v-E P(MOMTORIMje4" 114Yq) PYO�s V GROUT BEAL PUMPED: ❑Y. JB'Ne CONCRETEPEDESTALBYDRILLER:'1❑Yw ❑ S APPROX.DEPTH 1 �JJ LOCKING CREOLES BOXISTOVE RPE IIrdrdA" hemmly, PROPOSED CONSTRUCTIONAIRLUNG METHOD: MUD ROTARY AIR ROTABY AUGEfl CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED TRIG APPLICATION ANO THAT THE WORIK WALL BE DOE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENOED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CEWIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PEDMIT 18 ISSUED,I m1ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOYA '1 CERTIFY TI AT IN THE R BALANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA E P ANT U CA I mlmS IN ADVANCE FOR ALL REOUREO IINfNSP�Ef1CTIONS AAT�,Tn,In�Z 1 14404426. COMPLETE OORAW`RIG AT LOWER AREA PROVIDED. SIOnM% TIII. LAV JI,0y, •R--.Z2rLTZa11 l` �n"I�nC�e t D.I. PLOT PUN ID'.le Sew.)Se.l. I 'to 'T 0 4+ 1. NAMES OF STREETS OR ROAD8 NEAREST TO OR BOUNDNG THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING OWENBIONS ANO MGT"DIRECTION. EXPANSION OF SEWAGE DIBPOBAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DMVEWAYB,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. SEE AT-rACt4ED DEPARTMENT USE ONLY APPBealen Ao mtM By O.b / /J A— G'.0 Ir000elNn Br D.le Pomo In.peetlen BY 1 O.le De,lncllen Lw��ie�� By Daa CeC-1.1 �A T3C aFdybJoJ of U90✓L�J�I�Lr� ACCOUNTING ONLY: AID# FAC# 1 PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PORMITISERVICE REQUEST NUMBER INVOICE 2q333o I Pub.Health Sew.-Enviro.173(3196)