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APPLICATION FOR WELLJPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 40-3420 1101-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED mempl/t/In TIIpReatel APPLICATION IS kERE BY h1AM TO THE SAN JOAOJIN COUNTY FOR A PERMIT TO CONSTRUCT AHDIOR INSTALL THE WORK Of6CRIBEO,TIRE APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTYC*VEtGPWENT TITLE,CHAPTER S•1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PURIIC HEALTH eERVICE*,E"RONMENTAL HEALTH PAMBION, Joe ADORE80I0R AM$ CITYPARCEL aIIE .?07-2W-2 1 OVAWR'a NAME Ly,4_ ��(�(��. `�R �— _ ADORES 4 S� PHONf/ `/ ^ Sb0 I>L- CONTRACTOR {_ DINE AaS � / ~ P -1UCI PHONE f-41&--S3IAX SesCOWRACTORCI�YL.'OLorw4►�_I Ike- - - ADORE se 3 �A►c.11!a ! Apt. LfCf'.0 r PHONE f .too TYPE OF WIilA1PUMP: NEW WELL ❑ MKACEMEHT WELL MONrrOIJNO WELL• 3 ❑ OTHER_ 101 tHSTALLATION ❑ WELL SYSTEU REPAIR ❑ CItO*S.CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f ❑N.[:IF,,* H.P. DEPTH PUMP BET FT- FIRST WATER LEVEL Oz IT YPE OF PUMPT ❑ DUT,CF-VERVICF WELL ❑ GEOPHYSICAL WELL f — — ❑ 606.Ranima � S ❑nEerlwcrroN• INTENDE4 USE YPR OF VMCgNfTRUCTION/PEC ICA ONS y A LJ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 41_IjpJ_eL1S _ DIM,OF CONDUCTOR CASING In ❑ �,�y t DOMERTICMRIVATE 11GRAVEL PACKl61ZE�L /- ols TYPE OF CA.4Ge6TFEtA'%M - A1S . 4a SI _ DIA.OF WELL CANOIAaIJ. _ D ❑PUSLICIMUM MAL ►..J mm" DEPTH OF GROUT SEAL _ -- PA Es, 6 ,_ SPECIFICATION R ❑ 0IIh7ATpHlAG ❑OTHER GROUT SEAL METALLED,BY T.wt_M.i "5f. GROUT BRAND NAME_ �p��S. E (MONITORING GROUT 9FALHUMPED: 19Yw 0N CONCRETEPEOESTALBYDPILLER:blYw ON. S APPROX.DEF7N- -_yIS �cr LOCKING CHESTER MOXISTOVE PIPE OCH_ S PRObaED CONSTRUGIMR1DMLfING MIITTTOD; MUD ROTAM AIR ROTARY AUOER�i� CABLE OTHER I HEIEBY CLTTTWV THAT 1 HAVE PREPARED THIS APKMATIM AND THAT TIM WORK WILL RE DONE IN ACCOIOANI E WITH SAN JOAOUIN COUNTY ORMINAWE0.STATE LAW6.ANO RULES ANDg REGULATIONNb OF THE SAN JOAOUIN COUNTY, HOW OWNER OR LICEN/ED AGENT'/SIGNATURE CERTIFIES TNF FOLLOWING:'1 CERTIFY THAT IN THE PERFOH AANCE OF TIRE WORK FOR WHICH THIS PER OTT IS ISSUED,I*HALL NOT EMPLOY KR60HS SUBJECT TO WORKMAY'S COMPFHvATtON LUMPY OF Ct"OR NIA-' CONTRACTOR'S HN/NG OR MM-CONTRACTING MHATUFE CERTIFITIL- THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR%%%KH THIN PEPMW re ISKWJ,I SHALL EMPLOY PERSONS RLMUECT TO VOORMAM'/COMPOILA ON LAWS O>*' CALIFORNIA.' 71MANT MUST CALL 24 HOl1Ra AIICI FGR ALL TIEOUIRED IH1kNMTWPI8 AT 120/1 440-4!!. COMPLETE DRAWING AT LOWER AREA PROVIDED, n awwad R wc This "g, t' -veto .1 ROT PLAN Rkrw to 6eolel Semi* 1, NAMES OF#THEFT/OR ROADS MEANEST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUBE SEWAGE DISPOSAL SYSTEM OR rnDFOBED 2. OUTLINE OF THE PROFERTY,OHIO OIMEHSION6 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SY/TEM/. 8. DIMENSIONED OUTLINE./AND LOCATION OF ALL EXISTING AND PROPOSED ■. LOCATION OF WEtL2 VM 16M RAMS OF ONE HUNOIED FIFTY STRUCTURES,NfCLUDM CavE ED AREAS SIKH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOITANO PROPERTY. HuN-1 40 lio I IJew y ' s DEPARTMOIT U1E ONLY k� r ApMeaelen Aaaepwd BY^, (_L]S_L1,.Sf_'�� _ —..y�� _. Dn1 Z Arw G.eul I.npectlan S}_ 369dOQ Does �' 2r7 PLmp IAPeeilen B7 Leola Oeot—vlan Does Ca+ _mwa: ACCOUNTING ONLY- AID# FACE fE C004a FEE INFG AMOlIITT REIWTTED CHECKAFMASH RECBVED BY i DATE UER41T!/01VICE REO~IIUM INVOICE Pub Health Serv.-Envira.173(1/97)