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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 95201.384 (209) 460.3420 NOWREFUMDASEF P€AM{T EXPIAES 1 YEAR FROM DATE ISSUED WA"let$is TTip atol APPLICATQN It HERE BY MADE TO THE SAN JOAGUtN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL T44C WOW DESCRIBED.THIS APPLICATION IS MADE 1N CQ$,1PUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TLTLE.CHAPTER 9.11 15.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUUUC HEALTH GERVICES,ENVIRONMENTAL HEALTH WAf4DN, JOB ADDRE94"APN! `: ' � •��JCITY I �JPARCEL 617E'APNf J OWNER'S NAME ADOR66J fP,HNC 0 CONTRACTOR cea K AD... 20 ( �;r /V-[C /I / L" 3-71!j1) PF1pHE S SU6 CONTRACTOR ADORES$ LTG! PHONE TYPE OF WE'LUPUINP: NEW WILL ❑ REPLACEMENT WELL D WMTOwNO WELL! ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPMR ❑ VAPOR WRACTION WELL! J t; 1� Q..❑R., H.P. DEPTH PUMP SET fT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ OEOPHYIUCAL WELL IF ❑ SOIL ftrAING A ❑DESTRUCTION: 1NTENOED INE TYPEOF COHSMOCCTION SPECr"CATIONd i�❑ I/N�iUSTRIAL U OPEtt BOTTOM Zr OW OF WELL EXCAVATION a/..Of CONDUCTOR CAWNG JLC p i OOMf8T1C/m ATE GRAVEL PAMWE TYPE OF CAWNG,STFEUPVC � ,/ ULA.OF WFli CASING r f ❑ PUBLICMtWCIPAL ❑OFVAN r DEPTH OF GROUT SEAL J ewfr xII SPECIFICATION `1J t''�_Tp ♦.` RC ❑ IRtlV0AT10N1AG 13 OTHER GROUT SEAL IN OT ALLEO SY A r\- ORO UT BRAND NAME Cl MONITORING / GROUT SEAL PUMPED: Yr ❑No CONCRETE PEDESTARi L BY ORERI�Yr ❑No S APPROX.DO IN LOCKING CHESTER ACkSTOVE PIPE S , C PROPOSED CONSTRLICTIOWD18WM0 METHOD: MUD ROTARY�� Alla ROTARY AUGER _CABLE OTHER- -I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WRL SE DONE IN ACCOADANCE'MTH SAN JOAGI MV COUNTY ORDINANCES,STATE LAWS,AND RULES AND. REGULATIONS OF THE SAN JOAQUN COUNTY, HOLK OWNER OR UCENSFD AGENT'S SIGNATURE CERTIFIES THE FOLLOWING; 'I CERTIFY THAT N THE PERFORMANCE OF THE WOR(FOR WIVCI[ THIS PERMIT IS t9VUEO,I SHALL NOT EMPLOY PERSONS 6UBJECT TO WORILMAN'S COMPE14SATION LAWS OF CAUFORMLA.- CONTRACTOR'S HgWG OFLOU13CONTRACTOOO NONATURE CETTIFIERC THE FOLLOWINO: -I CFATI A IN N*E*EPMORMANCE OF THE WORIL FDA WHICH TWO PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORMAN'Y COMP00A NI L11W8�f1 CALIFORNIA.' �/ �CAjLr/�'(f�'yJ/�(J N,�D/ylt�IN ADVANCE POR ALl MOU ED ITN TONS AT 1100//444442/3. COMPLETE DFLAWING AT LOWER AREA PRO s*Ad%� 1�L --�? / l klo l t � -A I/�K7`— - �o PLOT PLAIN IDrow to 3"61 %off 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL RIYRTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,OIVINO DHJENSIONS AND NOMIN DIRECTION, EXPANWON OF SEWAGE OISPOSAL SYSTEMS. J. MMENDIONEO OtfrUW.9 AND LOCATION OF ALL EX181I4G AND PROPOSED 6. LOCATION OF WELJ-S WIT"N RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,NCLUOING COVERED MEAS SUCH AS PATIOS.DWAWAYS,ANO WALKS. ON THE PROPERTY OR AOJU00N0 PROPERTY. 2 L 3017 Gtil l'>+�SC PAYMENI . aL 2 4 1995 L'06LIC HEA. -r, C DEPARTMENT USE ONLY ADAMNt{On AcoopiM Grout hover wm BY LP 64t 011-> (" Drto Z Pump kwpection BY �'C-(/7_.f.^f'• f - -Dui l:•-I I -`� Dwt.vntbn Itrp.ctian dy Commard&: %4<-y-�!14 S C..�YO J� t,�>,: C �v'h_C L,. ��-If(4 � [. �C.(�.1''(T, c' �C.LF' Q r{:r FU�'rT LJT � K.J KS /C.Y�1 �.t V':.t+4♦�� L ACCOUMTINO ONLY: A1D1 FAC+I YE/.'DUEL FEE INFO AMOUNT RBWTTED NBC lICA44 RECEVIM BY DATE PMATISW64CE REQU"T NLAJWM RNV0ICE V' f ✓ 1~- 3 �5 '