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\j�/) E, V6 APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O. BOX 3K304 EAST WEBER AVENUE,STOCKTON, CA 95201588 f209) 461-3420 ( NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CBmpllb In Tr(pOeaE1) APPLICATION 18 HERE BY MADE TO THE BAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(UESCPoBEG.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENTTITLE.CHAFFER 8-1116.3 AND THE STANDARDS OF SAN"AMIN COUNTY PI16LIC HEALTH BERVICEB,ENVIMONMENTAL HEALTH UWRION. 1 OO a S JOB ADpREearoR AGPNa�.-1722�F/.aPA STREET' CNv�lOC1CT0/J PARCEL BIZF/APNF 2 �OOE n-OWNER'S NAME K ^ utT �� ZLI GT ADDRESS RE M. PHows yDF-1/Si��lef� VVsLLLTiWr L�uviCa/Y/LC( } � L �� 41BNFRABPOII ADDRESS /`b73L pA/m¢roD2. u14 ca A/!A PHONEaL -(e76-Gbyb_ G BUB COMMCTOR / �P/A! O;( e �1„ CR J/y Fc� l-j}F�M dT flp ICL/ 1[7 AoonEeaLICIT LI *54/979 PHONE a 9/6'638-7274 `e TYPE OF WELLPUMP. ❑ NEW WFLL ❑ REPLACEMENT WELL ❑ MONITORING WELL I OTHER C+U()TDAiM/•� �y, ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS{ONNECT REPAIR ❑ VAPOR E%TTMCTI YKU_II J • / ❑N.W❑RF o, H.P. DEPTH PIMP P IH TUFT. FIRST WATER LEVEL G u TYOF RIMPI �y ❑ OUT.or.m ICE WELL 13GEOPHYSICAL WELL I ' p SORA BORING /7' _of �/ B ❑DESTRUCTION: _ x%Sc/ INTENDED USE TYPE OF WELL 11NDU /w CONSTRUCTION WECIFICATIONa I, ISTRIAL BOAT✓(F ❑OPEN BOTTOM DIA.OFWKA t AWAABN p�JJ� .:"fJU dA.OF CONDUCTOR CASING NIA- D �-e ❑ DOMFSTICIRIVATE 11 GRAVEL PACK/SIZE TYPE OF CASINO/BTEE� IY/A DIA,OF WELL CASINO V,/q O ❑PVSUCANUNICNAL ElDRIVEN DEPTH OF GROW SEAL Vpj a4.a/ 6� SPECIFICATION R 11 mRIGATI)NIAG OTHER 14LN^^��•F�LArBP� GROUT SEAL INSTALLED BV 1L Qe1GROUT BRAND NAME' E W MONITORING / A. �J BMW SEAL PUMPED: W Y- ❑Ne - CONCRETEPEOESTALBYDWLLER❑Y. Ow A. APPROX.DEPTH E�•�•PMaTC, OG ff. LOCKING CHESTER BO%BROW PPE N/a a PRO/OSM CONITRUCTIONATRILIING METHOD: MVO ROTARY AIR ROTARY _ AMER X CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAUUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN"AMIN COUNTY. HOME ONINER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE KWORMANCE OF THE WOR(FOR WHICH TMS PRMR IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.. CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALFORNI THE APPLICANT MUST CALL 24 W VN IN ADVANCE FOR ALL REGURG IMSROMSI CTMS AT I4011 122, COMPETE GRAMM AT LOWER AREA PROVIDED. : ell,,.e% �Ivl - - TLD.D/JUER! "�A/Ui2.�sF ly .A4 1�F�3t./A�a/T�on. PLOT PLAN(Dr.H Saw.,B.w.�_•to �b L NAMED OF STREETS OR ROADS NEAREST TO OR MOUNDING MM THE PROT"N. 4. LOCATION OF HOUSE SEWAGE SYSTEMS.SYSTEM OR PROIOBED I. DIME N I OF THE PROPERTY,W ANGOCA DIMION OF ALL AND NORTH INR OMSE EXPANSION OF SEWAGE GRIMM aYSTFMB. 3 a.STRUCTURES, IGLUOUTIF.a ANO LOCATION OF ALL EXIAS PATO AND PROPUBED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. I STPoICTVTIEB INCLVdNO COVERED ARMS SUCH AS PATIOS,DRIVEWAYS,AND GAMS. ON THE PROPERTY OR ADJOINING FROM. PLEASE SEE C A"ct+ep F/6&)e4F,s f ctee. ! k/d i n i7� f1l410 F;�rlr 2 G51fe Plan _ f f I r ,;