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6bAPPLICATION FOR WELUPUMP PER SA OAOUIN COUNTY PUBLIC HEALTH SMICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDADEE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TEiplkoul APPLICATION IB PERE By MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 5-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AnORESSMR APHO 00 - aSo- c"r Cm, / O A6AT1'c PARCFLBIZE/APNF OWNER'S NAME 1214409P 41,TAA= WATTS- ADDRESS 17010 iJ. L e"A415-r IRSE AV / L-0p1R10NE I ZEA - LOFT CONTRACTOR OL4VA4 r't/1Ej CpAJ �- ,J•�. GL 941o7 C41 - ADDRESS_30! 2-W SrSLE q8O UCS PHONE I � l Bug CONTRACTOR PI'f DILII.LJAI Ey 40. ADDRESS P'0• 00X 60367 Z PMB.4L 4 2430W 1 RIONEI b2B'bgl0 TYPE OF WELUPUMP: ❑ NEW WELL ❑ nEPUCEMENT WELL ❑ MONITORING WELL E OTHER 11INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSSONNECT REPAIR ❑ VAPOR EXTRACTION WELL S J 11 N.❑R"ol, H.P. DEPTH PUMP BET_". FIRST WATER LEVEL G DYPE OF PUMP) f31.7yIR0(J• ❑ OM -SERVICE MLLLL.._''''❑ GEOPHYSICAL WELL/ A BOIL BONN; L_8IA-s'-S' B ❑DESTRUCTION:. APPrOk EW'0`"144.QA�d-fir 4e IM,0"ICAL~(Z-6 Age,pBy4N6P AIA1M2"t- , INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION S ��Q 4 DIA.OF CONDUCTOR CABIN; -- D ❑ DOMESTICIPRIVATE 11 GRAVEL PACK/SIZE TYPE OF CASINGIBTEEL/PVC Pllr, DIA.OF WELL CASINO I 0 ❑ PUBLIC/MUNICIPAL ❑DRIVEN � - --` DEPTH OF GROUT SEAL ^ 20 - T SPECIFICATION~'8TH NIP9 L 2.Z$Fid{_ 8 ❑ IRRIGATION/AG OTHER CPI�ZO J GROUT SEAL INSTALLED BY P ;VONT BRAND NAME E MONITORING ;ROUT SEAL PUMPED: Ys �. [IN. CONCRETE PEDESTAL BY ORLLLq:❑Yw [IN. S APPROX.DEPTH �T LOCKING CHESTER BOX/STOVE PPE 'SSWiEL PIPE 5 PROPOSED CONSTRUCTIONIINBLLINO METHOD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER 4 FDCL-i1r 0$>tiL.E9006CZWp1CF4dPF1 PIEYgMH�.-fA1$'CJELLfl,1�J Pla..c �- �MNIUL. WLR#—�. I HEREBY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I SHALL N9PdwqOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: IFY T T IN If ERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIIMAN'S COMPMSATON""OF CAUFORNIA.' R A PU ANT UST D HOURS IN ADVANCE FOR ALL REOURED INSSPIECCTIOONNS AT 12001144Nv- 22.. COMPLETE DRAWING AT LOWER AREA PROVIDED. /n SKS X Tills ✓ry 1 (�+i�r-4-,+� D.I. 4/ 14•/'1 7 PLOT PUN IM.le SaN.i 1. NAMES OF BTREFTS OR 8 NEAREST TO BOIINpNO THE P..... . 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THEPE ,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMB. 3. DIMENSIONED OV11mF.8 AND LOCATION OF ALL EXISTING AND PPOPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, KvP- Loud FIST l Wq��PIEZowt> 2-8�SS � pw-Ais ' Zee_ F=r "AF- i a'['t'Au�t�A.To t�d� E=/CPL47eAZTL1\I w�.l - F'I•M.I. :. � :. '' DEPARTMENT USE ONLY