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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC 5?�' ENVIRONMENTAL HEALTH DIVISION IF 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 JON 031999 110VAEFUIIDABLE_PERMIT EXPIRES i YEAR FROM DATE ISSUEN`1/r��r `�p r M;s WAmpMh M Triplk$t$I �IYIENTAL H` APPLICATION IS HERE BY MADE TO THE SAN JOAGUIN COUNTY.FOR A PERMIT TO CONStmx-r ANDIOR INSTALL THE WORK OE6CRIBED'��7��[�171b�kg��g--��--{{��p,rr66rr,lI �i� WITH SAN JOAQUIN COUNTY DEVEL `O OPMENT TITLE„CHAPTER 9-1115.$AND THE 87ANOARD8 OF SANJOA"COUNTY PUBLIC HEALTH SERVICER.ENVIRONMENTALTTEALTH�1, Jae AODRE88mFi APS, /-7-1 Sly 1U f acA st itat! _ _CITY (�_a�l _ _PARCEL BIXErAPNs OWNER'S NAME B�I�Q.1 We.11e� ADDRESS :Z 5 r--�rF - KSS S7Yg1Q/t�Q PHONE. �/�y J}'� CONTRACTOR AddRWLed &D�kIt#Tjpj&,e0fkLi-M X AbDREBB-�7 A/.�I IS��LICS V0Z PHONE,4.6 .1 0(a RUB CONTRACTOR 'r AOORESS LICE :PHONE S TYPE OF WEUJMMF- ❑ NEW WELL ❑ REPLACEMENT WELL © MONITORING WELL, ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRGe$" oNNECT REPAIR © VAPOR OCTRACTNTN WELL 1 1 ❑N.0&Pei, N.P. r DEPTH PUMP SET PT. FIRST WATER LEVEL O (TYPE OF r'UMPI 13ouT-0E-SERVICE wEit ❑ GEOPHYSICAL WELL, eolL RmRaNO { B sr.'1".TRLICTION• I D rJ f111K" bMOM'1 TTENDED US* TYPE OF_WELL - CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CARING D ❑ OOMESTIC/PISVATE ❑GRAVEL PAC1L18TZE TYPE OF CASMGMTEEL/PVC GIA,OF WELL CASINO O ❑ PUSLIGMUNRCtPAL ❑omvEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAO ❑0, GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING amu-r BEAU PUMPED: ❑Y. ❑Ne CONCRETE.PEDESTAL BY DRILLEIk❑Y. ❑N. s APPROX.DEPTHy Fe>'zT - _ -- LDCIIING CHESTER SOXMTGVE PIPE - s PROPOSED CON91R11CT1ONIOIBLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 7 . 1 tgPWBY CERTIFY THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY OROMANCEB.STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR'UCENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECTT43WORK MAN'S COMMIAT10N LAWS OF CAUPOWBA.- CONTRACTOR'S HIRING OR$U&CONTRACTNRT SIGNATURE CERTIFIES THE fOLLOWINO: '1 CERTIFY THAT in THE PERFORMANCE OF THE WORK FOR WHICH TMS PERMIT IS ISBUED.1 SHALL EMPLOY PERSON$SUBJECT TO WORIOMAWO COMPOTSATIOM LAWS OF CALIFORNIA.' THE APpUcANT MMT CALL 34 MOTHER eR ADVANCE FOR ALL MOUIR M INSPECTIONS AT x20814$$-2422. COMPLETE ORAVANG AT LOWER AREA PROVIDED. s T , 1 �. o� Bla,.e X I TIII., d+I�/� 12 B D.r. PLOT PLAN ID,. is Se.l.l sol-isf-- 'ro 4 3 f 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING TFIE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OutLINE OF THE PROPERTY.GIVING DRMENSIONB AND NORTH DBIECTION. EXPANSION Of SEWAGE DISPOSAL SYSTEMS. ]. OUSNPONED OVTLNFB AND LOCATION OF ALL EXISTIM0 AND am S. LOCAMN OF WEt.1$WITWN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,wmtNRNG COVERED AREA#SUCH AS PATIOS,'ORIVEYVAYS,AND WALKS, ON THE PROPERTY OR ADJORI M PROPERTY. :.-.... .. i... - - . i Y ......M. Ap ... ...... PIA ' :. .. _ :y _ ;0'•w..' DEPARTMENT UBE ONLY . LA Onto Mr 6 Z Pt.np Ift"."l.n SY O.I. Vs ' t�BOTRT!! MOI 'i .FACS poll o RpMTTEp CHBCK,ICASH REC9VED BY SATE 1N31NIRTlSERVICE REOLRpT NUMBER MVOICIE 15 .. r2 335 Tpina SrMro.173(1/97)