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. PPLICATION FOR WELLJPUMP PERM„ SAN.�OAQUIN COUNTY PUBLIC HEALTH SEH-VICES HEALTH DIVISION ! 304 EAST-WEBER AVENUE,';STOCKTON, CA 95202 (209) 488-3420 ROR•REFUNDABLf PERMIT EXPIRE 1 YEAR FROM DATE ISSUED !]I`} 1 ICamplsts In T►Tpll , APPLICATION IS MERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A�IWIIT.TO CONSTRUCT ANpfOR INSTALL THE WORK DESCRIBED.TI116 APPLICATION IS MADE 1N COMPLIANCE WTtTFI SAN 1 JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.11 15.3 AND THE,STANb(ARDS OF SAN JOAQUIN COUNT PUBIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB AbDRESSIOR.APN# HA}�i�0 WIWI WAY T¢y,KCf:M E`T �' T.,dA Rt .1TY s'1 O C 1 CrO N PARCEL SIZEfAPNf 466— j L [I'.i I OWNER'S NAMEJ1�I��/TV�'}AaVi rkIJLI l.64'E�i �E ADDRESS I. tG O�jO{/^*1r(L�{n��,j s TOCi�TaN 9s�zy no�t}PHONE, `66- 6/ 2az ' CONTRACTOR t YY {J I L L I j� • - FF T ! ADORES B {moi V sV iS l rte`r LICS 0 J LJ PHONE f � SUB CONTRACTOR ~' 'SI I ADDRESS a.. 1t —Z Tf 1 LIC# PHONE I> A TYPE OF WELl1PUMP: ❑ NEW WELT ❑ REPLACEMENT WELL` �Z 0 MONITORING WELL# 6 411 d ❑ OTHER - ❑ INSTALLATION ❑ WELL SYSTEM REPAIR'. If ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ l J ❑New❑Repelr H.P. ''-' I ! bwrH PUMP SET FT. FIRST WATER LEVEL' i 6 (TYPE OF PUMP) y:o ❑ OUT-OF-SERVICE WELL` . ❑ GEOPHYSICAL WELL f ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL ::,_I li'CONSTRUCTION SPECIFICATIONS t� �y y.l A ❑ INDUSTRIAL ❑OPEN BOTTOM 2 1 IDtA.,OFrIJ.EXCAVATION p �i hI C 14 �. GIA.OF CONDUCTOR CASINO+� tN A y,y !.i O ❑ DOMESTIC7PWVATE ®GRAVEL PACKIBIZE 3 SAN :.TYPE OF CASINOIST EELfl•VC__--_ C �f� y+ DIA.OF WELL CASINO F-. 1IN G rl I') v ❑ PUBLICIMUmcirl ❑ORtVEN _ i''i�DEPTH OF GROUT SEAL 3 0 ,FE E Ip SPECIFICATION �I 1',i R ❑ IRRIflATroNlAO ❑OTHER ,'dAOUT;SEAL INSTALLED BY' I) R I L L E R GROUT BRAND NAME N: AT CEM E3 E N�� ■ MONrrORINO /� 1-r "GROUT SEAL PUMPED: I♦V« ❑He r yC�ONLCCRE�TyE PEDESTAL BY DRILLER:❑Yr EN. ;:I s APPROX.DEPTH _TO F F E T ,.,_ -�!'!i a LOCKING CHESTER BoX16TOVE RPE 5•1 oy} PIPE E PROPOSED COHSTRUCTIONMRIl NO METHOD; MUD ROTARY :I' AIRI ROTARY AUGER X CABLE OTHER 'I t :I I HEgfBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT?THE WRK WILL RE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGEONT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,18HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'¢COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIflEB THE FOLLOWING; 'I CERTIFY THAT W THE PERFORMANCE of THE WORK FORi,WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERGONS SUBJECT TO WORKMAN'S COMP£NSATFOH LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR'ALL REaUIREa INSPECTIONS AT 12041409-2423. COMPLETE DRAWING AT LOWER AREA l k PROVIDED. ENV. CONSVLTANI OFte J p fa Jj `i: i1eldned X ylJ 9 w1 raSF_PiA AMA4E tr ��77rr F 14 _- f R 3 GJG PLOT PLAN IOiiw to Soelel Seale to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE _ e PF10►'ERTY.':' �.I• 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. .:I I 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND P11 06SED 'll,'E S. LOCATION OF WELLS WRHIN RADRIS OF ONE HUNDRED FIFTY FT. I STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. Ip : .... - E AT r A G t p 5 l..r,.:ki P;L:A I. . ' f - - - DEPARTMENT USE ONLY `� F APPlleetlen Ac—pled By 4 1{t Q Del•I GAro reet rKpeerlon By Date Pu p Inepanlon By Oete -1 beeln-filen Im"setien By ?1';,'. 'i. - _. I 1'. bele Cerr.merNe 2- W I,�tit 1 ACCOUNTING ONLY: qiD# �'',li4 �; FACf I� 3 ' jI ci PE caber FEE INFO AMOUNT REMITTED cMF M Ajj:SH �I RECEIVED ASH DATE ' PERMIT/SERVICE REQUEST HUMBEF1 ,,. INVOICE rl j Pub.Health%rv.-Enviro.173(1197) d. 1 1 I 1 1�