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f &PLICATION FOR WELL/PUMP PERMIO SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 RGEREFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComPloto In TripOMto) `�P-a P JOAWIN CDUNTY DEVELOpMEM Ti RIT APPLICATION I8 HERE B1'MADE TO THE BAN JOAQUIN COUNTY FOR A PEPLiR TO CONSTRUCT ANOMS INSTALL THE WOW DESCRIBED.THIS APPLICATION I8 MADE IN COMPLIANCE WSAN I _CNAPM 9-11115.7 AND THE STANDARDS OF SAN JOAQUIN COUNTYY,PVBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.. AB AOORE8SASR APNN.1f �1 �OS, d(nryy, CITY Ia'CK`r1lN OWNEII'E NAME J I e �� " I LL'^"_ + PARCEL 912F/2.5 /37- 3�o-oC (--T haw c... S l03 5. �I;,.,c.Q.....�1- ,S-�-L c.ktlf's zc z CONTRACTOR Re 6 G DR I LLI/J(> PHONE I C,Ns�Lrq APT ADDRESS 950 JGwe St /}�RR•T�A1GZ 9x.s uc, GS6y0'JP„DNE,3 3 -SHOD me OR— dLALMN 9 pr_LC+Z ApGAEse L Zo � r-D �L1 PLLMSR^" ONE, Z��Z�oC rIPE OF WELUPVMP ❑ NEW WELL ❑ REPACEMENT WELL9L5 ❑ MONRORING WELL I ❑ OTHER ❑ INBfµLATION ❑ WELL SYSTEM REPAIR ❑ CR08SCONNECT REPAIR ❑ VAPOR EXTAACTION'NELL, J GYPS OF WMPI ❑NSN❑Rpdr H.P. DEPTH RUMP SET_FT. FIRST WATER LEVEL O I• 11OVT-0E-SIAVICE WELL 11RI GEOPHYSICAL WELL, N BOIL BONG \` R 11 DESTRUCTION U ICFJ- � o INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N1 1� ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION A IN ❑ DOMESTICIPRIVATE ❑aAAWL PAC%/SPEDIA.OF CONDUCTOR CASINO D TYPE OF CABiNO/BTEEI,PVC INA.OF WELL CASINO C] PIBUC/MUNICiPgL ❑pAiVEN 11 IRRIGATION/AG Br'ECIFICATION DEPTH OF GROUT SEAL D ❑OTHER R GROVT SEAL INSTALLED By❑ GROUT SPAM NAME MONITORING SEAL PUMMO: ❑Ys ❑Np E APPROX.DEPTH SCONCRETE PEDESTAJ LOCXING CHESTER SO% TOVE PIPE L BY DRILLER:1:1 Yr Cl N. PROPOSED COMSTIIUCTION/pMWNG METNGD; MUD ROTARYS AIq iIOTARY AUGER CABLE OTHER HERE 1 EGULAY CERTIFY THAT 1 HAVE UIN C EO THIS C EIC WRIER AND THAT THE WOPL WILL SE UONE ER ACCORDANCE WITH BAN JOAOUtN COUNTY ORpiNANC£d,STATE LAWS,CAM. ANO REGUUTION9 OF THE BAN lOAOUIN COVNTY, HOME OWNER OR LICENSED AGEM'e SIGNATURE CERTIFIES THE FOLLOWING:'i CERFIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY pEPMMS SUBJECT TO WORmMAM'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOWS HIRING 09 MR- THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WOM FOR WHICH THIS PERMFF IS ISSUED.I SHALL EMPLOY PEARONS SURJEM CT TO WORRAM'STC COMPENSATION LAWS 10F CALIFORNIA.- THE APPLICANT IU T CALL 24 40L IN ADVANCE FOR ALL REDAIRM INSPECT((((((O111NS AT(MMM 4"Y23. COMPLETE DMWINO AT LOWER AREA PROVIDED. OF PUN IDrFw to SaWI 8aN. •ro I- NAMES OF STREETS OR ROADS NEAREST TO 09 BOl➢/,(y''NO THE PAOPEAFY•. 2. OUTLINE OF THE PROFERTY,GIVING DIMENSIONS AND NORTH DIRECTION. S. LOCATION OF HOUSE SEWAGE OIBPoeµSYSTEM OR PT101X)SFO 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING A EXPANSION OF SEWAGE al MSA,8YSTEMS. STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,,DRIVEWAYS,,AND WALLS. S. LOCATION OF WELLS WITTIIN MONS OF ONE HUNOAED FIFTY FT. ON THE FROM OR ADJOINING PROPERTY, . n - p �� l a /7," ApFSaSlISn A.eplad a /j GrM Inpepllen BF ONS ` C Mu O • Amp InpseB.n DaSmmyO Mwpmlbn BY Om DNS CmmmwA.: ACCOUNTING ONLY; AIDE FACE PE CODES FEE INFO AMOUNT REMITTED CHEC%f1CASH RECDVm DATE PERMIT/SERVICEEGUEST NUMBER RInvctcE v 6 % Pub.Health Se".•Enviro.173(1/97)