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APPLICATION FOR WELL/PUMP PT 10 JOAQUIN COUNTY PUBLIC HEALTHVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete ID TRiplkolAl APPLICATION M HERE BY MADE TO THE BAN JOAOUIN COUNTY FORA PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE MN SAN JJOAQUIN OB QUO EO COUNTY E DEVELOPMENT TITLE,CHAPTER 8-11 J 6.8 AND THE STANDARDS OF SAN JOAQUIN COU ffV TBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ,�//�(.(/Z &,,'S,4 �>hGC,/IC iJ'/L�/G/L/(/[//•t/AL� ✓-L Clry ! B /q �elo PnncEL e1ZE/APNIa�`/-390/0 OWNER'S NAME I't4-SI &, ADORE6E OO /�/L' ✓R �PHONER 8/i-SY9—.�9'Yp 7 VA r CONTRACTOR 0 r _ ADDRESS ivILY.E`�H•.[ uc# PHONE 6 92J'17o-39'70 9 0 SUBCONTRACTOR 4low//JLIZ-4- A/) TYPE OF WELLIPUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I -ZA C Z��D❑-r OTNER ❑ INSTALLATION [I WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR 3�L^G^tAQ-r.-4-`LJ VAPOR EXTRACTION WELL I J ❑Nev 13 Reeelr H.P. DEPTH NMP SET_FTJ �r FIRST WATER LEVEL O RYPE OF NMP) ❑ OUT OF SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORINO a ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM �E �/DIA.OF WELL EXCgVpt1ON /E/�h ♦ DIA.of CONDUCTOR CASING O ❑ NBL CIMVN CI PALE O DRIVEN PACK/SIZE" I ( DEPTH OF TYPE OF ASINGI SEAL VC��A Q o PIIS DIA.of w[ll CASINO 15-1 h D GROWSPECIFICATION ,-Y R ❑ IR GATIONIAO El OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME JE MONITORINO EW SEAL PIIMPEO:KY ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y. ❑Ne S APPROX.DEPTH J DISLOCKING CHESTER BOXISTOVE RPE S PROPOAED CONSTRUCTIONIOWWO METHOD: MUD ROTARY �AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS AP ATION AND THAT THE MW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,ISI/ALL NOT EMPLOY PERSONS SUBJECT TO WOAKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COW RACTOR'S HIRING OR OUR CONTRACTING SIGNATURE CERTIFIES THE F NG: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMR IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORXMAN'S COMPENSATION LAWS OR CA CANT MUST CALL ZR HO Wt IN ADVANCE FOR ALL REOURED INCSPE/CTIO/N///SAT I/Z/O,SI R�A,A-SSSS. COM/PISTE ORAtVINO AT LOWER AREA PKINDED. q SIP X TItM1 .J Z V"F� V�i{/CUl//S K D.ts �/1 .�7 PLOT PAN IDIeV1 Re BaJEI Svels 'to r / 1. NAMES OF STREETS OR ROA F ARE.T TO OR BOUNDING THE PROVERTV. /. LOCATION OF IIOVSE SEWAGE DISPOAAI SYSTEM OR M10ro6FD 1. OUTLINE OF THE PigPERry O NO OIMENBIONS ANO NOILTH DIRECTION. E%PANBION OF SEWAGE DISPOSAL SYSTEMS. ]. DIMENSIONED OUTLINES A LOCATION OF ALL EXISTING ANO PROPOSED B. LOCATION OF WELLS WITHIN RAOIUA OF ONE HUNDRED RFIY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. /r ON THE PROPERTY OR ADJOINING PROPERTY. YvIl rNl- ZS .. � Zo)•r f'YI-ok l'�`� ��n 1•L7nek ��isA.. �. ... .. + S ri c SIw1A _ DEPARTMENT USE ONLY APPlivsben neeepRM BY w w/ ��L. DMI S a/- 5 Mw 40 7 C) Grout ImeaRlen BY DELA PvnO lmpwtlen By OMa beemsRlOn Imnevtbn BY Oete Cemm,Mc ACCOUNTING ONLY: AIDS FACT PE CODES FEE INFO AMOUNT REMITTEDCHECXICASH RECEIVED BY DATE PERMIT/SEANCE REQUEST NUMBER INVOICE 30 G'-o S3jLg L' /`t 39`' Pub.Health SEN.-Enviro.173(1/97)