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APPLICATION FOR WELL,/PUMP PERMIT 0;1-07E:2,- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NOWNEFUNDABLE PERMIT EXPIRES 1 TEAN FNBM DATE IB=U7 D "IfTe In TFIPNIaEfX APPLICAYON NI NEVE BY MADE TO THE BAN JOAOMTM COUNTY FOR A PERMIT To CONSTRUCT ANOAOR INSTALL THE WORK DESCRIBED.TMS APPLICATION IS MADE IN COMRJ4NCE WRIM SAN JOAOUIN COUNTY DEVELOPMENT T}Rr .CHAPTER 9.1116,7 AND T,, IRE STANDARDS OF SAN JOAOUN NIHE COUNTY PUC HEALTH SERVICES,ENVOtoNI UNTAL ALTH DIVISION, JOS ADDRIA18'MR APw7 �A Y y,vr L(d� C, C' 7L PARCEL SIZEIAPW_ OWNER'S NAME N // AOOEN �O�/r Y BONE/ CONTRACTOR_ G rs7 P Se r U J Z a ADDPEfsPOW_ /0,76w; UcE "'Ham E l - f'�/ SIA CONTRACTOR_ ADDRESS T /�a '3 LIC. _PHONE. LR'E OP WKLIAISM^ ❑HEMI WELL ❑REPLACEMENT WELL ❑MORN ORINO WELL S ❑OT1ER ❑INSTALLATION 11WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAF014 EXTRACTVJN WELL E J 11111-UTM.P.I, H.P,�_ DEPrH PUMP SET_,EQFT. PAST WATER LEVIL , 71-7 O (TYPE OF PUMPI ❑OUT41F-WRVICE WELL ❑OEOFHYSICAL WELL I ❑ SOIL soRwi S ❑DESTRUCT.N: NTENbED ListO N S►ECIRCATIONS A ❑1 INDUSTRIAL ❑F� OPEN SOTTOU OIA.OF WELL EXCAVATION DN A.OF CONDUCTOR CASO D 1:1 DOMESTICRRIVATE 0 GRAVEL PACK/i0E TYPE OF CABINOISTIN UP/C OA.OF WELL CASINO b ❑%RBUCrNUHCS•AL ❑DRIVEN DEPTH OF GROUT SEK WfCITICATON A ❑IAIOATIO WAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑MOMTOA*m GROUT SEAL PUMPFD-❑Y- 11 N. CONCRETE PED[sTAt ev ORLLER:❑Vr ❑N. S APPROX DMH LOCONO CHEWER BoxISROVE PIPE__ S PROPOAEO CONSTRUCTORMPIN LINO METHOD: MUD ROTARY AA RpTARYAUGER CABLE_OTHER I HVWSW CERTIFY THAT I HAVE PREPARED THIS APPLICATION AHO THAT THE WOR[WILL BE DONE IN ACCORDANCE WRN SAN JOAOUMH COUNTY ORDINANCES.STATE LAWS,AND RULFS AND REGULATIONS OF THE SAN JOAO"COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWSO:'1 CENTFY THAT N THE PERFORMANCE OF THE WORK MR MRRCH THS PERMIT IS ISSUED,1 WALL NOT EM IRDY PERSONS SUBJECT TO WONDMAR'f COMPIDISAT10N LAWS OF CALFOFSOA_'CONTRACTOR'S NTNG OR SUBCONTIIALCTINO SIGNATURE CERTFES Tim FOLLOWING: '1 CERTIFY THAT N THE PERFORMANCE OF TAR WOW FOR WHCH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUUECT TO WORKMAN'S COMRNSATRON LAMS OF CALIFORNIA.'THS /MT WAY CALL XA NOW IN ADVANCE PDR ALL AEOII11 ED INIMMTI,OFS Ale "1460-24".COMPLETE DRAWING AT LOWER AREA MIOVIDMD Till. 'I //b e D. J-21—yJ ROT FLAN D'.RP 1•S.WI M.L 'te_ 1.NAW S OF SN TIECTS OR ROADS NEAREST TO OR BOURDO THE PSOPEArY, E,LOCATION OF HOUSE SEWAGE 01sOSAC SYSTEM OR PRIOPOSED I.OUTLINE OF THE ITOPERTY,DIVING DIMENSIONS AND NORTH DIFECTON. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ]. bIMENSK)NIM O4JTl1VE4 AND LOCATION OF ALL EXISTNO AND PROPOSED S.LOCATION OF WF3LS WRNIN PAMG of oRRi HUNDRED rim FT, LR ST RUCTII.INCLUDING COVERED ARDS SUCH AS PATIOS,DRIVEWAYS.AND W'."& OL THE PROPERTY OR ADJOLHNO PROPERTY. s . i .r .., isil :- 1.l . .. : , . SAtd XJLGON`.C'IeticESs FI IitvvlHL NMEMth1 r+` TMONIs1oN Dope „�...moi;. .L.... _. ....._.........:...........a...........a.....:..... 5.;1 RITC'.. D"ARTMINT VSE ONLY -Z--/,,,, T r APPS..—A...PI.d SY �JOWy ,A Anr— G,RVR kw fl—Sy P—P IANseeR SR ({:Lc<•.<_.—��VT" DN. y 2 v �C` Dew—c ,.up.ells:SY O.e. ACCOIJN TIRO GRIT: NO/ FACT PE COOTS FEE INFO AMOUNT MWTTM CH1EC ® SY ASN RECRVSY GATE TSOTVICS RSOUSST VOIC. 5 p Pub.Health Sam-ElrAro.173(1187)