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IOAPPLICATION FOR WELLIPUMP PERMIT or N JOAQUIN COUNTY PUBLIC HEALTH SERVIC� ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (2091 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ORIGINAL (Complete IR TrgFieatel APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMA INSTALL THE WORK DESCRIBED.THIS APPLICATIGN IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMEN IT CHAPTE 9-111 .3 !0 THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE8.ENVIRONMENTAL HEALTH OMSION. C}T� ,yam ^ L370.c Its JOB ADDRESSIOR APN'. ' CITY J1 U'C k+CIA` PARCEL SIZvAPN/ OWNER'S NAME ,' ✓ C ADDRESS440b" A _ PHONE -,q P CONTRACTOR H 21b1 H II�L(r-- /C_I. /�.v(/QG C-- .&1/J RE86 QC1'�( "1 VJL.,, � Lfi:.r LIC( { p''?PHONE/LJ-r - �/`.�S-'1J BUB CONTRACTOR �L'C 1 / U� FXY) ` 1(0 C-✓1 ADDRESS STS/ VPI I CCL GCa S I Z2 CO R1GNE I1 S V J I Z TYPE OF WELLlPVMP: ❑ NEW WELL ❑ REPLACEMENT WELL Ly MONROWNO WELL/ K P r-15 ❑ OTHER ❑ INSTALLATION C1 WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAI `,3 t> ❑ VAPOR EXTRACTION WELL/ J KP-35 ❑New 13RePMr H.P. DEPTH PUMP SET—FT. K� UI C FIRST WATER LEVEL O TYPE OF PIMP J ❑ OUTCF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ BOB.antum S ❑DESTRUCTION: INTENDED USE TYPE OF WELL N , t CONSTRUCTION IIPECIMCATIONS c'1 A ❑ WOUSTRIAL ❑ F4 BOTTOM MCN}CTSy DIA.OF WELL EXCAVATION �I IU HS!3 DIA.OF CONDUCTOR CASING D ��11 r cc ❑ DOMESTICIPRIVATE LPACX/SIZE SCL04A TYPE OFCASINGlSTEE[ I+yC 4'TU J�NCL(I(If 4-0 DIA.OF WELL CASING p ❑ P1BUC/MUNICIPAL ❑DRIVEN DEPTH OF GAD DT REAL L16Cl�iW 8_ J SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME N (} P1'l!P✓L t E MONITORING GROUT SEAL PUMPED: gyr Ne CONCRETE PEDESTAL BY ORIIIFR Y. ❑Ne 5 APPROX. DEPTN Sra IIcEW ZZT Deed � / LOCKING CHESTER BO)USTOVE PPE - \ TT1L �L,+ed 'Flu s i,, I'NC I:1'1'r s PROPOSED C0146TRUCTIONIDWLLING METHOD: MUD ROTARY AIR ROTARY AUGER-4/_ CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS AP'UCATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,ANO RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFYTNAT IN THE PERFORMANCE OF THE WOW FOR WHICH MIB PERMIT IB ISSUED,I$HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAMS COMPENSATION LAWS OF CALIFORNIA.- COMPACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFlES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMfT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APRUCAMT MUST CALL 24 IN ADV ANCE FORA EGURED INSPECTIONS AT 120e1 AYJA22. COMPETE DRAWING AT LOWER AREA P^IO—VIDEO. 9lynsd x�� (PLOT RAN ID,.w 11.S .I Sow le 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. D. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATON OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,OAV E AYR. AND WAIXS. ON THE PROPERTY OR ADJOINING PROPERTY. ... v _ i ......._._. OEPMTME T USE ONLY APPIIe.IIen A.. IM SrN « G'.tA Imveetlen 8, D.m Pune ImeeeOan aY / l D.0 DeanA-tlen Imv.eOon BY pas OPmma .: 71uuc XPS' SS c t q5 — au. ,Qoaal d /3•PQ ACCOUNTING ONLY: AID/ FAG PE coo" FEE INFO AMOUNT REMITTED CHECK//CASH RECDVED BY DATE PEVAITISIERMCE REQUEST NUMBER INVOICE o1 �0 s o y