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SAYAPPLICATION FOR WELL/PUMP PER JOAQUIN COUNTY PUBLIC HEALTH S ICES i ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-U20 WON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED Mample[a in Tripliealal 4 APPLICATION 18 HEREBY MADE TO THE SAN JOAOUSI COVNTY FOA A PERMIT TO CONSTRUCT AND/OR rNSTALL THE W&k DESCRIBED.TMS APPLICATION IB MADE IN COMPLIANCE 1MTIi SAN S JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNW PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB AODRESSIOR APNI D n CTI__J r6�GG] ... PANEL SIMAP OZZ OWNER'S NAME r r bI p/',G f' ADDRESS/S3/ (r.2rT! T G. .)e/1 1 'Ca, �� PHONE f/L/10'1�I-71-�0 S �Ssyo c s�'` CDNTRAcrORG7�1%/O. �.T.akn&1t s S.SO ,jAUDRESB�,�- h6Vyk,14..�o�' _.�LcI.669DD1_PHONE0 347-3791 SUS CONTRACTOR ADDRESS LACE PHONE TYPE OF WELL/PUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTORING WELL ❑ OTHER - ❑ WSTALLATK)N ❑WELL SYSTEM REPAIR ❑ CR098-CONNECT REPMR ❑ VAPOR EXTRACTION WELL I ❑Naw❑Ra.alt H.P.. DEPTH PUMP SET FT. FMIST WATER LEVEL D (TYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLI ❑ SOR samm S :R!OESTRUCTiDN: r•T746, s CW-C iNTEMDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS K A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Sl.. Z Du.OF CONDUCTOR CASINO D ❑ DOMESTICIPRIVATE ❑GRAVEL PACIKISIIE TYPE OF CASINOMICELJPVC DIA.OF WELL CASING D ❑ PURI-WIFAUNICIPAL ❑ORVEN DEPTH OF GROUT SEAL V I- 1 FrITsJ SPECIFICATION x ❑ IRRIGATION/Ad ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME /fit l,t iF f i ❑ MONITORING GROUT SEAL PUMPED: ❑Yr f,�Na( w,nl/Et), CONCRETE PEDESTAL BY MQUAR:❑Y. 0 n S I �y E APPROX.DEPTH -ti _2-0 LOCKING CHESTER SOXATrOVE PIPE s ` PROPOSED CONSTRUCTIONADMLUNG METHOD: MUD ROTARY AIR ROTARY AUGERCABLE OTHER r I HEREBY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND -I REGULATIONS OF THE SAN JOAO"COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGT Y CERTIFY THAT IN THE PEWORMANCE OF THE WORK FOR WHICH THIS PERMIT PS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORIMAM'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CqPVFY THAT IN THILMCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORIWIAM'S COMPENSATION LAWS OF CALIFORNIA.' T AMT MUST 2 H01ARS IM ADVANCE FOR ALL REGURED INSPECTIONO AT 12081 48aJM". COMPLETE ORANRNG AT LOWER AREA FROVIO Slo.od% TIB. /-,`Lt), Gala - PLOT PIAN(Draw to Seelel Seal. to 1. NAMES ZRIEFTS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPARSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXTSTIHG AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR AOJO"M PROPERTY. A AolAx, &di 4 L f Ta'L20S Gaut Una ...... ............ I ti DEPARTMENY USE ONLY - Aeplie.1fon Aetxptd BY0 Otl. Mir O,o rt I—mctlen Rv r'1 V D.te Pi v Inataetlen BY bat. beatntellen bweaotMn r Date l - r. d� 1, comaMt: r. s I - 1 ACCOUNTING ONLY: AID/ PAC/ y FE CODES FEE INFO AMOUNT REMI"ED CHECKPICASH RESEBIVE14lIY DATE MIMITASF7WICE REQUEST NUMBER INVOICE y 5DZ O r Q 0jqTl /irCl Z / I Pub.Health Serv,-Enviro.173(1197)