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&PLICATION FOR WELL,/PUMP PERMI* SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 488-3420 ! c 3 -5. L -.. NON-REFUNDAREE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE 0 3J��/yJ APMICATION IS HERE SY MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT TO CONSPRUCTIANDIOnINSTALL THE MW DESCRIBE 113 APRICATION 16 MADE N COMRIANCF Wrtll SAN JOAOUIN COUNTY DEVELOPMENT TTf(E,CHAPTER 9-1113,3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH 6 CFS,EM/IRONMENTAL HEALTH DIVISION. JOB ADDMS&ORCAPNJ j. _ L` r�`r',_,,....- zt CITY -5, OWNER'S NAME J�O GFG.Lp>>. L ^ �n/n p PARCEL SIZEJAPNI /37-3�o -p6 o^ ADDRESS If ` ,S��r " ISZ oZ CONTRACTOR f 'C e,G I ( I p/� PHONE t C.JSULTA NT ADDRESS I Y00 S- .Sd-4St ' IJ , GN Slo n /1 / UCG�G38V PHONE.-ns-7-Y Run T `�LI�D N ADDRESS 10 92q KOLL r- r(c Pk�u' 1 LeRsAr�H01'� yzG"z`,� ONE I ZS TYPE OF WELLPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL t ❑NewH ❑ ✓ FeP.b .P. DEPTH PUMP SET_FT. FIRST WATER LEVEL R VM OF PUMPI J ❑ OVT-0E-SERVICE WELL ❑ GEOPHYSICAL WELLtn IL O ❑DEBTRUCTIGN: l /r '601E BORING P{.1 S r n 431 e 1 c nLia, 1 iENDE USE TYPE DF WflL C NBTR TI N 6PFCiFl ATI ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION A ❑ DOMESTICPRIVATE ❑GRAVEL PAC%/SRE DIA.OF CONDUCTOR CASINO D TYPE GROUT SEAL DIA.OF WELL CASINO N ❑ PUBLICS.IUNICipgl ❑OrvVFN DEPTH OF OROVf SEAL O ❑ IRRIGATION/AO 6E4CIFICATION N OTHER SHOUT SEAL INSTALLED BY MONITORING SPOUT BRAND NAME E GPOVT SEAL PUMPED: ❑Y. ❑Ne CONCRETE PEDESTAL BY DRILLER:Ely- ❑Ne S APPgO%,DEPTH LOOSING CHESTER BOX/STOVE RPE PROPOSED CONSTRVCTIONIDRIIUNG METHOD: MUD AOTAFYS AIA ROTARY AUGER CABLE OTHER I HEeEBY CERTIFY THAT I IIAVE PREPARED THIS AP, ATION AND THAT THE WORK WILL BE DONE IN ACCOIIOANCF WATH SAN JOAOUIN COUNTY ORDINANCES,STATE UWe,ANp RUlEB ANO REGULATIONS OF THE SAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE E TIRE WON(nUUSICH THIN PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUR-CONTRACTING SIGNATUREFOR CFR:IFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT tS ISSUED.I SHALL EMMOY MlUP)NS SUBJECT TO WORNMAN9 COMPENSATION LAWS OF CALIFORNIA.- THE APKIC NT UST CALL 24 HOUR,IN ADVANCE FOR ALL MOURNED INSPECTIONS AT Uo01 Mmm A"- COMPLETE DMWING AT LOWER AREA PNGVIDEO. ftX Tllle z y L]-L D.Is MOT Mil IOr.w to%e .I Se.w le I. NAMES OF STREETS OR MADS NEAREST TO OR BO NCINO THE PROPERTY, 61 Z. OUTLINE OF q. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED DISPTHE PROPERTY.OMNO DIMENSIONS AND NORTH DIRECTION. O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS EXPANSION OF SEWAGE THIN RADIUS SYSTEMS. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALXS. ON THE PROPERTY OR ADJOINING MUS OF ONE HUNDRED FIERI R. PflOP£RfY'. �� as If e . ..... Apgiwlbn At,BY. DMFLL,,4V `Hr Groh Imoxrlan BY C.te l�ppq,„ Dm Dmvwlbn impeclbn Sy D.Le Cammemc ACCOUNTING ONLY: AIDr FACS PF CODE] FEE INFO AMOUNT REMITTED CHECUTAAN NEC ED BY, DATEI 2 PErtlM1TIeFAV CF NEGVEET NUMBER INVOICE I Pub.Health Sew.-Enmrc.173(1/97)