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APPLICATION FOR WELL/PUMP PER SA AOUIN 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 (Complete IR TTiplke+el AMICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPUANCF WRIT SAN JOAQUIN COUNTY DEVELOPMENT TREE.CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSOR APN# ��O�� —s, —OIty - ry OI Clfti � PARCEL SIZE/APNF ONMER'9 NAME O1�a 9•-WTV ADDRESS- -4 A.S WeST / 'VA K -quQ `SIS PIONEI 2$_7 i3S8. CONTMCTOR puJ1A C$40 l �'<hIS1r1LTA{�l�i/ IAfr . ADDRESS �5 ZN� ST SY�9SO S. UCE� 94107 PHONE SUBCONTRACTOR PITOHEFL- P12.11LPj64O• ADDRESS PM8JIZsCS ao 7 uCF Zb:icay PHONE# Y� -8l— J9{•D/o Au=m a TYPEOF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I 15 OTHER PIe^"f/F -RR- L2-16 !• 2-�8, ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 9 J ❑New❑Rep.lr H.P. DEPTH%IMP SET—FT. FIRST WATER LEVEL O RVPE OF PUMP( ❑ OUT OF-SERVICE WELL ❑ GEOPHYSICAL WELL 6 SOIL BORINGV{ JLT•1+•M1g11'6V.. B 11DESTRUCTION: Q- -rQ FJE__ W9rM4LJrO CZ'16 & 2-18 O mL� —I 56-6 TD ELJ-ScP WISH' fa TYPE OF WELL ye CONST 11INDUS RIIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONTION68 DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEUEFVC IG�L DIA.OF WELL CASINO lee p ❑ RIBLICRAUNICIPAIL OWNER DEPTH OF GROW SEAL ^/ 25 r- 30 a SPECIFICATION- $r SAND RIL•EF4 k 2 e5Fj1LR 11Itl IRRIGATION/AO OTHER (Q{�ZQt,.Y�f� ,) GROW SEAL INSTALLED BY QLSGiVC-R-. GROW BRAND NAME E 19 MONITORING GROUT SEAL PUMPED: ❑Ys [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr 11 No S APPROX.DEPTH 1 V LOCKING CHESTER B0XI9TOVE RPE 5'6'PVE QEpig- 5 PROPOSED CONSRUCDONA RILUNG METHOD: MUD ROTARY__AIR ROTARY AUGER CABLE OTHER 7W PW-A 0IM ptLJeDyB%6cRZPtiBj W- rWzcttMC ' IWMAA 1-�, A*"e- SES 6F6dAS4F W.A - 0XIoLVOgpi l WOR*- PLAA• 1 WGIEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND 714AT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.6 ATE 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 WOR(FOR WMCH TIIIB PERMIT IB ISSUED,I SHALL NOT APLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY 794 IN RIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS BUBJECT TO WORMMAN'S COMPENSATION"We OF CALIFORNIA.' CANT UR L M MOMS IN ADVANCE FOR ALL REQUIRED INePFCDONe AT IMeI 40114MI21, COMPETE DRAWING AT LOWER AREA PROVIDED. Sl'—I X ' TIS. i'134EtN IZ Dn. I•f I3 A7 MOT PAN(Draw to Seal.)Seal. •to 1. NAMES OF STREETS OR ROADS NEAREST TO R BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED Z. OUTLINE OF THE PKIP.RTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWARE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY P. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. • FOEWVA'� or— PARS-L/.P�'I-0M@y1:<K. � 2-66 MID .2-18/ CL-AEP- SJER- PKLLKE, Q AT a 7 400'MW440IC4d4- E#FCPL WMJL a,l n1 APR LCCA*&PJ &r- .F _.:2, 19/s¢.-s, ae�s,�, SES RtiweE.• 1• ,ATTAu}E-0 smolt, sFawµA,r„ .aAle-,�,a�ysrs._ wo+.1 . -_ . ... ..... D.R.