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APPLICATION FOR WELLIPUMP PERMIT LSAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 386,445 N.SAN JOAOUIN ST„ STOCXTON,-CA 95201.398 ' (2091468-3420 4' !, MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED [Complete in Tr(plicvlaj APPLICATION 19 HERE BY MADE TO T1rt SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT •TITLE,CHA ER 9-11 Y513 AyNyD�1HT STANDARD-ST OF RAN JOAOUIN COVVNIr PUBLIC HEALTH SERVICES.ENIRONM1RENTAL HEALTH DIVISION. JOB AODRESSKUn APNI f-y C}r -� T 11 Ir l I 4� �I('1-t, CITY .J`'G C.i�l �/ : f ��T P� 1 PARCEL SR{!A7'N/ rrII(� OWNER'S NAME (�sc. OIJ tj C, �o0l ITra I'I S q Y��-.ff(.Q ADOflE6B ! 5 .< GSao PRONE/•zU EM co IJ ' 1 CONTRACTORF!>.IJt7G. ADOPT S-4 ' r mer LIC/ PHONE/ IL} t8-j3Pe svBCDNrrwcrGR G l 2 Il`�; n�1-� UCTc-57 r?U403Z$PHONEFVIo 60Q-LIy4L ADDRESS P ➢r o TYPE OF WELL/PUMP: ❑NEW WELL ❑REPLACEMENT ❑ WELL MONITORING WELL/ ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ©CAOS6-CONNECT REPAIR ®VAPOR EXTMCTMN WELL III W`I New 13 Repel' H.P- DEPTH PIMP SET FT. FIRST WATER LEVEL 0 y RYfE OF PUMP. � ❑OUT-OF-9ERVICE WELL ❑aEOP1YSICAL WELL$ ❑ BOIL BORING 9 ❑DESTRUC716N: II-.-ITE 1.USE TYPE OF WELL CONSTRUCTION SPEVI1IC.T..Nf Q,U " _ A LJINDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �7 U DIA.OF CONDUCTOR CASINO p ❑DOMESTMIPWVATE ❑GRAVEL PACKISIZE TYPE OP CA61NO1STEELIWC//.�T�G v~ DIA.OF WELL CASINO -I IF O ❑P%mvc AMUNCIPAL ©DRP/EN OEMH OF GROUT SEAL ♦P SPECIFICATION' r3 L .F Q It ❑IRNa AT1ON/AG ❑OTHER GROUT SEAL INSTALLED BY f I M 1A+ GROUT GRAND NAME E ❑ Y 11 YLDjIING�M-F {)lrT'1 0 YY GROUT SEAL PUMPED:111Yr IJ Ne CONCRETE PEDESTAL SV ORU":❑ TT//��Ys Ly Ne S AFMOA..DFKPT. I r LOCKFNO CHESTER .STOVE RPE S PROPOSED CON@TRUCTIONIOIUWNG METHOD: MUD ROTARY AIR ROTARY AOOER_X CABLE OTHER I HE9ERIY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,ANO RULES AND REGULATIONS OF THE SAN JOAQUIN COVNTY.HOME OWNER OR LICENSED AGENT'S BIONATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORC FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EM OY PE NO SUBJECT TO WORKMAN'S COMPOPBATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUSLONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT INT PE O MANCE OP E 5.011(FOR W1{ICH T11P8 PERMIT IB RISVED,f SHAD,EMPLOY rER6ON8 SUBJECT TO WORKMAN'S COMPENlATION LAWS OF CALIFORNIA,• T DANT ST A A� TO S 1N ADVA EE WA ALL REG111HF�INEPECTeON@ AT r2 �ef.1.1MIL COMry7113 WINO AT LOWER AREA PRO O/fE[7D ACC Slen.d X /l./ Tule ' / ;17 .1 �Q PLOT PLAN IOrew ea Saerel Seele 'to ' 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, A, LOCATION OF HOUSE SFWAGE DISPOSAL SYSTEM On PROPOSED ' T.OUTLINE OF THE IROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, G. DIMENSIONED GUTURFS AND LOCATION OF ALL EXISTING AND PROPOSED ■,LOCATION OF WELLS WITMN RADIUS OF ONE HUNDRED FIFTY FT. ' STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOI}FINO PtOTERTY, a d` ✓1;`�x, I� 1 i� Mw 7N�D<g5 �� . ND<0. ND<O, - Nor MEASUREO scmicE NOT MEASURED .. _.. _ 0 StATION sun DING f : L J Pro O SPENSER i.. ISLANDS IIIIOERCROV11p .. ..: USED DIL TURK 7HP-I FTD':t PTD 3 ., >8000 —1 370 I�O2 34 T 70_ 0 Io Doa3�0.l9NOMESURED. . .. I I it MIN I II For J �I✓W-1 ON flWNO ' NU<O. N <U. FUEL t�tNN$ !: . .... ........... 5..._; .... ., - NOT MEASURED '...,..:....,.... ....._ '.- .. : PITH TER . ., :.. ...:....., - ORNLWAT - .. -•- RRANSTORNER I DEPARTMENT USE ONLY ApPECelbn Acee W By 6[7/�S/f/A✓/7yIvJ armd Ine Rlen BY Det. P—P 1h.Pen11on by 3 n.Pe Oeelnietlen fmpwjlen 8T Dele Cemmen � ACCOUNT...ONLY: AlO.I FACT PE CODES ........ AMOUNT REMITTED CN /CASH RECEIVED BY i DATE PFPADTISERVICE REQUEST WOMEN INVOICE SO 11 z!