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APPLICATION FOR WELLJPUMP PERMIT O �/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION P.O. 60X 3881904 EAST WEBER AVENUE. STOCKTON. CA 86201388 (2091408-3426 NDN•REFUNDANk PERMlT EXPIRES 1 YEAR FRDM DATE ISSUED (Comp16te In Tt41fe6t61 APMICATkTN IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INGIAlt THF WOFW TWIIrRIREO.TRIS APPLICATION IS MADE IN COMPILANCE WTTII SAN JOAGUM COUNTY DEVELOPMFIFT TITLE,CHAPTER 9.1)16.9 AND 711E WANOAAOS OF BAN JOAOUIN COL/Nfy PUBLIC I$EALTII SERVICE!,ENVIRONMENTAL MMTH DMNON, .los ADOTE891071 APNE D061-1^DaT3�_t�3/ 000�� T�E.� KE•I" EMAN LN r_Ire 19,.19 WDI rAAcF,BLzuArNi_Po(' 133—�3 OWNER'S NAME—• E3ELFORD TTIZERRICH ADDRESS 7848 E. KE'.PTi,EMAN LANE LODI RIDN!/ 334-2012 CONTRACTOR PREEZUR ELEMIQ & P-W SER. ADOMOO816 N. SAQEAMEhT Uc,F Z77%7 vtoNEE SIX CONTRACTOR AAnRF SD IICI —`M10N! TYLE OF NMUM Mt+. ❑ W%V WELL 0 I�PLACf.MENT M/FlL l ❑ MONTTO'-MO WELL I ❑ OTMR ❑ INSTALLATION ❑ WELL SYSTEM REPAIR '` FK1RB f.ONNEC� T�IE�� ❑ VAPOR EXTRACTION WELL I ,I ❑to. ❑Iw.lr H.P. DEPTH FV _IT, FRIRT WATER LEVEL p RYPE OF PLOW ❑ O rr-or CEnvICF WFLL ❑ nFOPIrYSICAI WFLL f ❑' ROIL BORING y ❑DISTRVCTgNt /t` IN FE100 f I YX OF wMCONST ION CPKIFICMION6 A �V7 ❑ INO(1eTRIAL OPEN BOTTOM BOTTOM DIA.Of WEIL EILCAVA110NDIA.OF CONDUCTOR CABINO D ❑ DOMESTICA"VATE ❑GRAVEL PAUL 1012 TYPE OF CASINOIBTEFI/L'Vr DIA.OF WELL CASINO b 11 PIOBUC A.KIMC PAI ❑ONVEN bfl•TH OF ORnlli SERI Sr4GIfTC AT10N R ❑ I19 AT1ON/AG ❑OTHER GROUT SEAL 11497ALLEDF-'BY Mtow BRAND 1yA FI�� f ❑ MON TO" GROUT SEAL PUMPED: Q Y.. ❑N. CONCRETE PEDESTAL BY DRILLERS L..J Y. ON. s OTS M APPROD.DSTII LOCKING CHESTER BO%!STOVE Pwf — CONS7IROCTIOII/DNlI1N0 ETHOD' MILD 110TAM_ AIR ROTARY AUGER CABLE IN`R 1 HEREBY CERTIFY THAT I HAVE PIIEPAMO TMS APPLOCAT"A"TNAT THE WnRX WILL RE DONT IN ACCORn ANCF WITH BAN JOAOWN COUNTY ORDINANCES,STATE LAWS,AND RULES AND�O MOULAYMMS OF THE SAN JOAQUIN COUNTY- HOME OWNER OR LKIiNS(D AOENT'S SIGNATURE CEnTIF1ES THE FOLLOWING! •1 CERTIFY THAT IN THE PFRFORMANCE OF THE WOR;FOR WHICH TMS PfFIMff IS)SHOED,)A#ALL NOT EMPLOY PERROM SUBJECT TO W\7PYIMAN'S COMPENIA TION LAWS OF CAL WORM.A.' CONTRACTOR'S HnWMO OR SUS-CONTRAC"NO NGNA TLRE CERTIFIES THE FOU.OVANO; •1 CERTIFY THAT N THE PERFORMANCE OF THE VM-V.FOR WHICH THIS PERMIT IS ISSUED,I NIA:LL ENM•LOY PERSONS SUBJFCT TO WORRAIIAN'S COMPOISAMN LAWS OF CALMO 1l�A1VIT CALL MAJIMURS IN ADVAMCE FOR RLL REO MID!N1PELIIONI AT 1"614119.10421. CoUr%rrE DRAWING AT LOWER AREA PRO%AOED. IH#... ROT PLAN INaw 1.S-1.4 Tle.1. ee 1. NAMED OF SIAEFTS OR ROADS NEAREST to OR BOUNDING THE PROIEITTY. 4. LOCAIION OF HOUSE SEWAGE DISPOSAL SYSTEM nR PROPOSED P. OMU E OF THE M DIRTY.GIVMIO DDAFRIMONS AND NORTH OH1ECI ION. EAPANMON OF SEWAGE DIRPOM SYRTEUR. 2. DTIAE/11FDE1EO O4JTLfW9 ANT)LOCATION Or ALL EXWT040 AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FKTY FT. STRUCTUFEB.PKLVDDM COVEMID AREAS SUCH AS PATIOS,ONvEWAVS,AND WALKS. ON THE PROPERTY OR ADJOININO P"D EK", i � , .. � .... !�� ,✓117 � � .• t .. ..,..> .... �... ..; ... •.. ..........t... .. .... i .00 14• i • : . .:5EP 27 1996 RVICE O"ARTMUiT USt ONLY A#p8.111...An..p1d BY DM. Mw /__.. R.np ST �.A r. pt4n ST O.. ImDeellen EL b.t-00.b.Ip.etl.n SY„ D.t. ACCOVNTMO OIKY7 AID# PE CODE) FRIFRFO AMOUNT RVAITED IIEC R:ASII RECEIVED■Y DATE ►F71MTI1tIN1Ct REQUEST N111N691 IINOICE 3(T �� Y - 91a7jQ d3a- .i Pub.Hebhh Serv.-Enviro. 173(3/96)