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APPLICATION FOR WELL/PUMP PERMIT �� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 J / (los) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l / ( V►`" IComplet9 In TTIpResta) cz APPLICATION 19 MM BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MAD I COMPLIANCE WTTM SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.111 5.3 AND THE STANOARD9 OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICED.ENVIRONMENTAL HEALT VISION. JOB ADDRESS/On LPN/ ` CITY LZ'447:/ PARCEL 81ZE/APNI OWNER'S NAME "AW�}y / / DOREB8 [% /)G4�r PHONE CONTRACTOR /:/KL '–AbDRE88 b PHONE I 0 PVD CONTRACTOR ADDRESS / � �C��_UC7 •�G/ R10NE f 5�L—Z- e2 TYPE OF WELI HUMP; NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER INSTALLATION ❑ WELL S� TEM REPAIR ❑ CnOS9-CONNECT REPAIR ❑ VAPOR EXTMCTK)N WELL# J H YPEYPE O °w❑R.n.lt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL A&L O ❑ OUT-OF-@ERVK;E WELL ❑ GEOPHYSICAL WELL# ❑ ROIL BORING 9 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL C❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING ~—� 0 DOMESTIC/PRIVATE }�,(IRAVEL PACK/SIZE TYPE OF CASINO/STEELJrVC /,py^ _ - DIA.OF WELL CASINO A O PUBLIC/MUNICIPAL 'guy.RIVEN DEPTH OF GROUT SEAL /(i'y{,/ SPECIFICATION ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY rj/�T DLit-�--�� GROUT BRAND NAME E ❑ MONITORING • � GPGROUT REAL PUMPED .. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y.'". S APPROX.DEPTH /7/�� LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTION/DI@LUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WMCH T1419 PERMIT 18 ISSUED,I SHALL NOT EMPLOY PER90NO SUDJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING 91GNATURE CERTIFIES THE FOLLOWING: IRIFY T T IN TT PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAW@ OF CALIFORNIA.' T A UST ULS IN ADVANCE FOR ALL REQUIRED INSPEC12ONS AT 12051 4SSJ423. COMPLETE DRAWING AT LOWER AREA PROVIVIDE @IOn.d X .�� TIt1. _ V D.1. G �a PLOT PUN ID.µto 80.1.1 S-1. 'to 1. NAME@ OF STREETS OR ROADS NEAREST TO OR POUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAGE D48POM SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPER7Y,OIVM/O DIMENSIONS AND NORTH DIRECTK)N. EXPANSION OF BEWAOE DISPOSAL SYSTEMS. J. DIMENSIONED OUTUNF8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELL@ WTTMN RAOMB OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUOING COVERED AREAS SUCH AB PATIO#,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOIRM PROPERTY. _ .... dA ti DEC 1 sk'14 JUAQLIIN GUUNTY, PUBLIC HEALTH 96NVICEO ENVIRONMENTAL HEALTH DIVISION DEPARTMENT U."E MNI.Y –) ApPI1..lid:AeoepteA 0y Armes Groin I-p–Uen 6 �('}/'"+rd.�/.�/M lc� / .es ,CTP':wnp ln.Ooollen By D-tttmtlen I—tlen BY D.1. C o--t v. ACCOUNTING ONLY: AID# FAC/ PE CODES FEE INFO AMOUNT REMITTEDCHECK ASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE (12