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` APPLICATION FOR WELLlPUMP PERFAr , S& aAQUIN COUNTY PUBLIC HEALTH SER_ ICES ENVIRONMENTAL HEALTH DIVISION k 304 EAST WEBER AVENUE, STOCKTON, CA,95202 (209)468-3420 h 1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR F800 DATE ISSUED 1C9mplet9 hL Tr196estal II APPLICATION FS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED,THIS APPLICATION IB MADE M COMPLIANCE WI II SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARD9 OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. 'rJOe ADDRESSIOR APN! 11012- k+6 S T 1.t A*%+As2 L-r.„ CITY 5 Toa,C-coO l.� PARCEL MMAPN! 1 OWNER'S NAME Ad Lo P20D'jC-r6 <-Cl--?, 4. J C� -,14- L'70 SOOD - tyl ADDRESS PHONE! t,.rd If ¢,o Ls, c E i 3�d CONTRACTOR ��t<o C�Lw✓G ADDRESS Po gp 336 , LICO710,0:" - - , ,,...,._. , �TYRONE d r' SUB CONTRACTOR ADDRESS �i L.C. PHONE/ i III ,f TYPE OF WELLIPUMP. NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I Iii .` OTHER A I Q. 5 PA?AF—' AS–I, --L,'3 i 13INSTALLATION 1:1 WELL,SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR I I VAPOR EXTRACTION WELL f V 1/ - ❑Naw ClJ Ftnpolt H.P. DEPTH PUI.1P eVr FT. :r FIRST WATER LEVEL O [TYPE OF PUMP! ❑ ❑ SOIL BORING OUT•OFSERVICE WELL ❑ DEOPHVb1CAL WELL! �+ g ❑DESTRUCTION; Ii i .i. INTENDED USE TYPE OF WM CONSTRUCTION BPECtMCATIOMS i'r ,� A '+ .w ❑ INDUSTRIAL 110OPENEN BOTTOM VIA.OF WELL EXCAVATION S�Ir<-10 1C _Ic rA.*-P' +- 4, DIA.OF CONDUCTOR CASINO p ❑ bOME9TIC1PIIVATE 9ORAVEL PAC%lBIZE =2 �F STA'e`PE OF CASINOfSTEEUPVC C4 I DIA.OF WELL CASINO KI__C%4 Ot A 0 ❑ PV'RUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL • 4'T BPECrFICATON SC+4 A-0 F-4 C- R © IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E �iaG,,�Et71 MONFTDRING jA-vi I-X3 GROTTY SEAL PUMFEqIRk- ❑Ne � ;Y CONCRFTE PEDESTAL BV bwLLERh❑Y. [IN. 5 APPRROX,DEPTH LOCKING CHEBTER BOXISTOVEdPIPE 5 PROPOSED CONBTRUCTIONIDMI-LINO METHOD; MUD ROTARY AIR ROTARY AUGER I{ r „CABLE OTHER _ - !l M I HENRY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WCM WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUPTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED ADENT'9 SIGNATURE CERTIFIES THE FOLLOWING;,'i"CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORWAN'S COMPUMATRON LAWS OF CAUFOANIA.' CONTRACTOR'S HIRING OR BU"014TRACTING MNATVItE CERTIFIER THE FOLLOWING; '1 CERTIFY THAT IN 711E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS i@@UED.I SHALL EMPLOY PERSON$SUBJECT TO WORlOYIAN'9 COMptl19ATTON LAWS OF i CAUFOMOA.' THE APPLICANT MUST CALL 24 HOUM IN ADVANCE FOR ALL REOIBRW INSPECTIONS AT 12091 49!.9427. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slened X TM• flu/�Sr�—�4-9.It:QGu T Oata.�.fJ-� - PLOT PLAN Wyt to goww Seale I FfL-i 'to 219'�r-T ,I 1. NAME@ OF STREETS OR"DADS NEAREST TO OR BOUNDING THE PROPERTY, �I 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM QR PROPOSED i 2. OUTLINE OF THE PROPERTY,DIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SY9TEM9. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EX16TING AND PROPOBEO ;i S.-LOCATION OF WELLS Ul rwm RADIUS OF ONE HUNDIIEO FIFTY Fr. S STRUCTUREB,INCLUDING COVERED AREA$SUCH AS PATIOS,DRIVEWAYS,AND WALKS. qON THE PROPERTY OR ADJOINING PROPERTY. . .:.. .t ..... .................... :..............:......:........ OFDARTMENT LIFE ONLY 115-115K I A..Aieatren Ae ted Br 1 o` -+1 ONo Ar" O.Pui`h�seeetbn BY Date I0 21f Flanp l�vtreeden h i� Dote if Oealna:tlen trnneetlen BY j Date Cmnn.nnta• I1 .{;. .. .• ACCOVNTINO ONLY; AID# FAC! fi ,I PE CODES FEE INFO AMOUNT RE V'rFD CHECK/ICASH I RECEIVED BY DATE 13 P9VMITIBFA'VICE REQUEST NLJM9H1 INWOtCE Ste'© .00 050�Z, C, lS Pub.Health Serv.-Enviro.173(1197) - . 1