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-------- &APPLICATION FOR WELL/PUMP PER' S. JOAOUIN COUNTY PUBLIC HEALTH S...L ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (CBmplate In Triplicate) APPLICATION IS HERE BY MADE TO 111E BAN JOAQUIN COUNTY FOR A PERMIT 10 CONSTRUCT ANDIOn INSTALL 1HE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE Milt BAN JOAQUIN COUNTY DEVELOPMENT TWE.CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. c� JOB ADDRESSOR APNI S TU C K-T U N /-) V L'y CITY r I E��!� CH 953 GJ !moi PARCEL SIZE/APN/ Z 5�� 5)0 "gip OWNEn'B NAME N✓= -S'7' /.-If_' u 'T. ,5 n y:,<� p,q�r'_�Ici+ q l i^o- ( F) ADDRESS Qi—f- +3�,I � � RIONEI S-f-F-5946 CONIRACTOR 27 C-2 Po/t .q .-- ac�n! •T 5'T KNOT. 9Je. 'rn. PgOHE# A0011Eee.Mq?YI ally jl- m ID, c/ ri3G/'7o RIDNE/ . -39Vn SP7'-'c'r LaGS tcs wqM prz, rr11// (Zu '1 — OUSCOINMCT011 'tt(-4'J SNHP�lZq Tlo%rJ 1N LJ'ADDRESS �6z dcK ION (_.q UC/SIPL.\1p R10NEIT�>l-� l/2+ Iq q-& ' M TYPE OF WELUPUMP: Ly NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER11RO INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CSS CONNECT REPAIR ® YAPBN47 E%TMCTION WELL I �--Z J C�•`ZIANP(_G^'. [TN. 13 Rw.E H.P. ZS OEM"Pump BFTcoC>ET. FIRST WATER LEVEL O (TYPE OF PUMPi ❑ OUT OF SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ BOIL BONING B ❑DESTRUCTION; NTENBED U89 YP O WELL CONSTRUCTION SPECIFICATIONS A ❑ INWSIRAL ❑OPEN BOTTOM A.pNJs1-r 4OIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CAGING O ❑ WMESTICMIUVATE 190MVEL PACK/SIZE Pi. ^� TYPE OF CASINO/SI EEL/PVC , S rl Z'/ {'� �ktBHA.OF WELL CASINOCID I O ❑ PIIBUCMUMCIPAL ❑DPVEN DENIAL OF GROW SEAL U SO I SPECIFICATION Yt C V4 A ❑ IRRIGATIONIAG ®OTHER ♦z Y 'j 1L/4 Loma GWUrBEALINBTALLEDBY Spr-_' �7✓y LAM GROIvr BRAND NAME *QSA 2- r% E ❑ MONITORING GROUT SEAL PIMPED: IN Yr ❑No CONCRETE PEDESTAL SY DRILLER:®Y« ❑N. a APPROX.DEPTH 701 LOCKING CHESTED BO% OVE __ -f— S PROPOSED CONBTRUCT10NI0ALUNO METWB: MUD ROFARY AIR ROTARY AUGER k CABLE OTHER 1 NMBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THEWORK WALL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND MOULATIONS OF TIIE BAN JOAOUIN COUNTY. IIOME OWNER OR LICENSED AGEW'B SIGNATURE CEMIFIEB TIIE MUOMNO:•I CERTIFY TIHAT IN TIIE PENOnMMCE OF TIIE WORK FOR WIIICII IIIIBPEOMIT ISIBGUED,I SHALL NOT EMPLOYPERSONB SUBJECT TOWORKMAN'a COMPENSATION LAWS OF CALIFORNIA.- COWRACTOR-S HIRING OR BUB CONTRACT IND SIGNATURE CERTIFIED THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE L1A�APPPLICANNT/IMUST LL 24 WIAS IN ADVANCE FOR ALL MOUNTED INSPECCTIO`N1$IAT IMSIL4409A 23.. COMPLETE DRAWING AT LOWER AREA PROVIDED. /Ip/ 611. % I )I Y I l TIO._ j"TjJTm �Gr PLOT LUN IDI.w 1.Sow.)Bu.N •to 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE OMPOOAL SYSTEM On PTIOPOGEU L OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DINEC71014. EXPANSION OF BE'WAOE DISPOSAL SYBTEMG. O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. SIRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DNVEWAYB,AND WALKS. ON TIIE RIOPERTY•OR ADJOINING PROPERTY. P 1 a I : - ...... .... .. :... � ins. j a. le v � . .... DEPARTMENT USE ONLY p Appllp.11pn A--led BY D.I. L9 Omm Imp..Sm:a' O.I. r P.I1P hop..Spn BY DU. Uveal.Ileo 1m,.allon BY DO. �7 cemmo-n.: 2 - J S ILIO L L. ScG<..rJ' LJ It').S v� 1A .,S - u 7 / A, (vCLhc1A1 c> 'i'le, ACCOUNTING ONLY: AIDS FACS PE CODES FEE INFO AMOUNT REMITTED C IEC /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE oZ © G7(e 8 OEC Pub.Health SEN.-Enviro.173(1/97)