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r PLICATION FOR WELL/PUMP PERMI10 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM GATE ISSUED 1�P- !a, 131 4 1-5- (Complete S(Complete In Trip5catel APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMPI INSTALL THE WON(DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WHIZ SAN JOAOUIN COUNTY DEVELOPMENT TTITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BM JOAOUIN COUNT-YF PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESSIOR(AP�N# t.S s 1'/N T�)QX.�-� /� -CITY S 1 -Cohn 1'^J PARCEL BIZEJAM# 13 I �� I OWNER'S NAME (JN+DI.�u N\MOTH C�JA_�, Z)L-)JLA4- "00 ADDRESS P•O- LJ O ( 1, /I ISL -tg,�C( CA FROM COMPACTOR r P 1 S 10 ADDRESS 1 T�� 5_ Sa-4S I I`r I 0 SIO Ce NSU "TMw I �I U, �/.�8 PPHH HE, (/ @us COMMAC I 1R-- C LA 4-m/j ADDRESS�9 Zu KO(_L ctR• y 925 TYPE OF WEUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL E- 13 OTHER 11INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL A J 11 N.❑Repdr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL n O HYPE OF PUMP) I.L ^ 1y ��r ❑ OUTF L�O6ERVICIE GEOPHYSICALn WELL C❑ GEOPHYSICAL W],EII�ILL/ 'BOIL BONNO .L 11./�a ❑ '-DESTRUCTION:1 /J'A �12A�- AMGr�- ni1 /.11 �/LQ/Y1✓N'��4.. I-YL I TENDED USE TYPE OF WELL , CONSTRUCTION SPECIFICATIONS Y A ❑ INDUSTRIAL ❑OPEN 80TTOM DU.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D Lys` ❑ DOMESTIC/PRIVATE 11 GRAM PACK/SIZE TYPE OF CASINGMTEEINVC DIA.OF WELL CASINO D ❑ RIBLCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION B ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E 11 MONITORING GAOUTSEALPUMPED: ❑Ys ON. CONCRETEPEDESTALBYDRILLER:❑Yr [:IN. 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE RIPE S PIIOPOSFD CONSIRIICTIONIdaWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAMIN COUNTY, NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CEWIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOMIA.' COMPACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWMG: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT[a ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPIJC NT NST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INIMCTIONO ATTJIj 4011 A22, COMPLETE DRAWING AT LOWER AREA PROVIDED. wo—I x TIO. T'--TSI e_. A 0.1. Z-I 6Z RN OT PLAR)r.v.le Scol.l ae.l. •le 1. NAMES OF STREETS OR ROADS NEAREST TO OR B dr NDINO THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND MONTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUMS ANO LOCATION OF ALL EXISTING AND PROMMO 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. LSP - ;�- 1� �5r sih Jz � r 025 -- — /1 D@MTMMT UBE ONLY ee Avpliv.tlen AepleA H, ///�- V L/ G-W BY D.la P .Peellen EY L D.I. OminleSen lmpenibn BY O.la Cemmdea ACCOUNTING ONLY: AIDE PAC) M CODES FEE INFO AMOUNT REMITTED CHECKIMASH RECEIVED Y DATE PERAIH/IERvICE REQUEST NUMBER INVOICE Pub.Health Sew.-Enviro.173(1/97)