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At(PLI6TIONFOR WELUPUMPPERMIT `-> AN JOAOUIN COUNTY PUBLIC HEALTH SERVICE./ ENVIRONMENTAL HEALTH DIVISION ' +r RO!BOX 988 904 EAST WESER AVENUE, STOCKTON, CA 95201388 (209) 408-3420 ' - NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED 1Complate M TfIpRE11Rl' - ppp"""''' APPLICATION 18 HERE BY MADE TO THE SAN"'OWN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRII SAN JOAUUIN COUNTY DEVELOPMEENT TRLLE,CHAPTER 8-1116.3.AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,EN SPONMENTAL HEALTH OMBION. �E•OC ACRES JOB ADDRE88AIq ACR1fc__rI/22e.�Lopa 117/Z L'FT - CTf 57&AVTOA1 PARCEL BRE/APN. •C./y�A9 - n1 �po OWNER'S NAME ..w=G F1YT'AP41 f� n 1 Ej'� IE O cT ADVAESS .st r.aF SIF, FRows //D9-Vcl-nIn C EA/�/A30a/F/.a C,.•1 I '>daTS ADoaEss /L,73L PG�n.E,-,,/)O. uDF QA RroNE I_(�,IR"GT/ _ �MIC.O.N,1BUCQTCa ' ADdasSAd- O%t LoCn+C2/z8 u-cF554979 RwNrq/6_b3g.7Z7t TYPE OF WELURIMP ❑ NEWWELL ❑ RERACEMENTW ❑ MONWORINO WELL# • OTHER} J .1/�. '❑ INSTALLATION, ❑ VIELLBYBTEM PAIR ❑ CPA95CONN[CT AFFAIR ❑ VAPofl EX MCTTMIN'wE^_LL"/' I/Li/J ❑New❑RePMr H.P. DEPTH RIMP.SET_�FT, flRBT WATER LEVEL O V ETYPEOFPUMPI p 1_ ❑ OVF-0f-SERVIOF WEII ❑ oEOPL1VGICAL WELL i P Solt eonGM M7AL of 4 e ❑DESTRucTION: I0EpN'I YL%So# INTENDED USE TYPE OF WELL .1 CONSTRUCTION SPECIFICATIONS A ❑.MotoU At $0 1116 -❑OPEN BOTTOM NIA CIA.Ora-,. --,..• /�-,A��G G J/ MA.OF CONDUCTOR CAGING ❑COMESTIOIR11VATE ❑GRAVEL PACK/STTE: TYPE OF CASINGRTEEL 4e. W4 dA.OF WELL CAGINGova - O ❑ PLreIK:IMlINIO1PAL ❑DRIVEN - DEPTH OF OROM SEAL-oval! I".O .O'(.^,o.,�F- SPECIFICATION - p ❑ O RIGATION/W '�OTHER C KAmek-T- GROUT SEAL INSTALLED BY Q I , CAP, GROUT BRAND NAME - E �MOIMORNO p ['' r11 .. GROW SEAL RIMF£O: �Y. ❑Ns y CONCREfEPEDESTALBYORLLE0.OYr One S APPROX.DFIfN F[}.ee-A�P- LOCKING CHESTER SOK/STOVE PIPE S .� �CONSTIIUCTIONIORILUNO METHOD: MUD NOTARY. - AIR ROTARY AMER- x. CABLE OTHER � tr I HEREOY CERTIFY THAT I MANE FREPARED TWO APPLICATION ANO THAT THE WOR(WILL BE DONE IN ACDANC COaE WEER SAN MAWIN COUNTY OPoNNANCES.STATE LAWS,AND RULES ANO PEGUIJLTIDNB,OF,THE BAN JOAOVIN COUNTY. HOME OWNER OR LICENSED AGENT'S BIONATUM CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PEWORMANCE OF THE WOW FOR WINCH TWO PERMIT"MUSLIM.I GRALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOWG HINNO OR 6USCOMMCTOm SIGNATURE CERTIFIES THE FOLLOWING! •I CERTIFY THAT IN THE PERFORMANCE OF TWE WOR(FOR WHICH THIS FERMTT M ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CNffORNI4 �4\\\I THE APPLICANT MUST CALL 14 HOURS IN ADVANCE FOR ALL MEOW W INSPECTIONS AT 120111 441111O 22. COMPLE/TEEDRAWING AT LOWER AREA FPoVIDED. J SbtadX (y/��,�� t � illla��✓U� ✓�A./1/2 IF/� LL✓,Al/,�SOe,a v a PLOT PLAN O to BaYel BeNe_�•to � I. NAMES OPSTPEETS OR IIOADe NEAREST TO 4 AM MA THE UiCTIO TV. 4. LOCATION OF HOUSE SEWAGE d OYOTE SS. OR PIgPoSED 3. ON ENGO OF THE PROPERf V,OINNG O N Or AMB ANO NORTH OPBOE,6 N, EKPANSbHL OF SEWAQE dePoeAl ES OF OS. . - G.-dMENSIONED'OV1EfNfB'RNO.IIVCATRIN OF ALL'[KISTgiO AHD PgoPo11ED �' ' '�"- �'--' E. LOCATION�OF WELLSVNT1111l RAONS OF ONE HUNUMED FIFTY fT. I STIII/CTURES,IMCLUdHQ-COVEIRO AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPENTY OR ADMININO PROPERrY. . .Pt..EASE SSE, A7>*WeHt,a FlGuR£s , � 1 , v i:diS / .. .. L .a DEPARTMENT USE ONLY I Applbetbn A-v ,f BY Data At. �. Maul Impeelbn BY Det- &A L R F,ImpmUen By Date Dwinvlbn Iwpmlbn BY Dala - �, rr Ce.nmwee /' ,aW/ ACCOUNTING ONLY: AIOP FACE _ PE CODES FEE INFO AMOUNT REMITTED CNECK#/CASH .RECOVER BY DATE 0,9MDT111ERVICE REQUEST NUMBER INVOICE 2 2 Pub.Health Sam.-Enviro.173(3/96) G.