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r_ a APPLICATION FOR WELIJPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 MOR-REFU{TOARLE PERMIT EXPIRES 1 YEAR FRO>R RATE ISSUED ICempIHe In TripReelal APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH 8AN O" ON.COUNTY DEVELOPMENT TITLE,CHAPTER 9-111,,5.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH BERES,ENVIRONMENTAL HEALTH DM0N. JOB ADDREBB/OR APN,38S7 WaS (2mvt+Liy- CL- Cm P�rTG �y PARCEL SIZEIAPNI OWNER'S NAME —"��L ADDIF ESB, O 7 CONTRACTORLTDIu1 V.N ADORE ! LICI �rjE R ;Er'S 7 � 6VB CONTRACTOR 7' G 49-ADO a juilo DCI `PHONE#� -2�1 TYPE OF YYELLIPUMP: ❑ HEW WELL ❑ REPLACEMENT WELL ❑ MONItOIQNG WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO86-CONNECT REPAIR Cl VAPOR EXTRACTION WELL# J (TYPE OF PUMP) ❑Naw 13RapaN H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I BOIL SORTINO B ❑DESTRUCTION- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INOUBTRIAL ❑OPEN BOTTOM GIA.OF WELL EXCAVATION_ _ I I �.S ., DIA.OF CONDUCTOR CASINO p ❑ DOMFBTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CABINGISTEEL/PVC DIA.OF WELL CASINO p ❑ PUSLIC/MUNICB'AL ❑DRIVEN DEPTH OF GROUT SEAL__... 2SPECIFICATION a ❑ IR{pfGAtIONlAG OTHER � GROUT 6EAL INSTALLED BY -kt jAjtT GROAT SAND NAME N ( p ❑ MONITORING ( GROUT SEAL PUMPED: ❑YM [IN. CONCRETE PEDESTAL BY DRILLER:❑Y. �Na S AP X.DEPTH_ • _ LOCKING CHESTER BOXMTOVE PIPE 5 PROPOSED CONSTRUCTIONIDNILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 Hf9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT INN WORT(WILL BE DONE IN ACCORDANCE WRtH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERrlDRMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL Not EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALWOF"A.- CONTRACTOR'S"RUNG OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT INTIDE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP009ATYoN LAWS OF CALIFORNIA.- t ANT MUST CALL 24 HOURS IN ADVANCErI �F�OR ALL HEMMED INSPECTIONS AT 12061 40!3123, COMPLETE DRAVNNO AT LOWER AREA PROVIDED. Slpwd X --=GL�1 1?C..•��LAW or-11dTltla_.-- p f� �,..._ // _ ^� Q `��).R t CY'!�D l�f i J Data_ ,....!_j PLOT PLAN W sw to Soatal Sala •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED x. OUTLINE OF THE PROPERTY,OWING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTEMS. 3. DIMENSIONED OVTUNF.S AND LOCATION OF ALL EXISTING AND PROPOSED e. LOCATION OF WELLS WITHIN RADIUS OF ONE NVNOIED FIFTY FP. STRUC7URE6,INCLUOINO COVERED AREAS SUCH A$PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. �v►v ass. . DEPARTMENT USE ONLY AppRaatRan Aeg"ted BY /_�'y/1�"��` "Y ONa .�'I%-' A,M07 T Grout hopaettan By Data Pump Impaelten By Oat■ Drwtrintbn Impeellen By Data Cwnmenta: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED HEC ASH RECEIVED ST DATE PERMITISERVICE NEGUEST NUMNER INVOICE ZS'D t r l 7C 0 3 l `t d l q(o Pub Health SerY.-£nviro.173(1197)