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SAMAPPLICATION FOR WELUPUMP PER OAQUIN COUNTY PUBLIC HEALTH S ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompl$t$In T/IpREnt$) APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOEL DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESOMR APNF .�] C A C 1,q .4 V-4-=' CITY 1-I P--A) CQ S3 Cw C� P[�RCEL SIZF/AM# Z57 3 V. OWNER'S NAME !�-I(;.S 1"e LSSA ADDRESS GLrNQA.>,-r z C/2 4tz-a3 m 1PHot'lo S�-`)-54" ZT CuYZp� 7$7 AAt.�Ia a..Q O/2. 5I5'. P• 192 k A.T 3J/� PH ADDREet M�fR zJ,.JSSa.cA 94553ue$53CPi7o O 970-39@ CONTRACTOR V 0 '�L3'-3 f�'TT 2 G (_ 4�Q a T. iEE / AUB CONTRACTOR w.'= ;> -" lY%i�,M 7' 126L I c_..•N� T J-?P- ADDMBS ,•'JNt'-+io eur- c c,g& C.l LN: 12 5 7 PHONE/ �3�-727G �j� TYPE OF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL A MONITORINO WELL Ln-2_4 C-Z ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ❑N.❑Revdr N.P. DEPTH PUMP BET-FT. FIRST WATER LEVEL U (TYPE OF PUMP) ❑ OMOF-6ERVICE WELL ❑ GEOPHYSICAL WELL A ❑ BOIL BORING B ❑DEBTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / A ❑ INDUSTRIAL ❑ryC�OPEN BOTTOM v.VET 75"IA.OF WELL EXCAVATION / `� 'JL4- DIA.OF CONDUCTOR CASING "�/A O ❑ MMESTICIPRIVATE E GRAVEL PACKISIZE 4F-� TYPEOFCASINGMTEEL/PVC ,SCT/ �� PCi DIA.OFWELL CASINO ' D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL O -!jv .'7u-JP.Fj�` SPECIFICATION (/2yc' A A❑./IRRIOATIONIAO ❑OTHER GROUT REAL INSTALLED BBY/`-al"'� Z '442/' �p��IIOVT BRAND NAM O T/IQ'n �G/1-E ,1 MONITORING BMW SEAL PIMPED:WY. C1N. CONCRETE PEDESTAL BY ORILLER:firy. Ne S APPROX.DEPTH 1 ?0• LOCKING CHESTER BOX/BTOVE RPE Y S PROPOSED CONSTRUCTIONIDPLUNO METHOD: MUD WTAnV_'AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOM WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN-$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTINO SIGNATURE CERTIFIER THE FOLLOWING: •1 CERTI fFHAT IN TIIE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION"We OF CALIFORNIA: T AP FF MUST CALL a HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT/12MI 404 J 22. COMPLETE DMLMNG AT LOWER AREA PKINDED. / elae.a N FIG. / S T7—r C_-f4-/,A. ✓T 0. C!� 11 CY(A Cl%pq INR\ KOT�PLAN 10,w 1..a W.)&.I. •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF MOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWAOE DISPOSAL BYBTEMB. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOBED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAE SUCH A8 PATIOS,DRIVEWAY8,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. -Sri 174 R �i .......... . i J. /J DEPARTMENT USE ONLY ^� nPPllv.11en A..evled Br �/�'/IALyL D.I._ (ice 2- 1 A,. G `-2 3-( \p Oreul ImoevBen By O.ro PvnP Imveetlen By V.I. Ow•buellen ImP.vllen Br u D.1e Camman.: U /� NCr Go t 41 7 C46 ACCOUNTING ONLY: AIDS FACT PE CODES FEE INFO AMOUNT REMITTED CHEC (CASH RECEIVED BY DATE PERMIT/SEAVICE REQUEST NUMBER INVOICE .2cI01 Cj' — ILP(ou Co 6 S Pub,Health Sew.-Enviro.173(1/97)