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APPLICATION FOR WELL(PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCFCTON, CA 95202 (209) 46&3420 NON-REFUNDABLE P RMIT EXPI III 1 YtA R FROM DATE ISSUE IComplet6 IN TT1pneate1 APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND)oR MN9TALL THE"W DESCRIBED.TRIS APPLICATION IS NAGE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPR.AENT TITLE,CHAPTER 0-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PURLIC HEALTH SEMMES,ENVIRONMENTAL IiEALTH DIV MN_ JOS ADDRESBA?R APNf I P '�_W. s .e11 AV If __ CITY [c r't PARC.t EIZEIAPN/ 21&9- z U" 2I OWNER'S A `'"f^f ADDRESS He,n VIOS,31:4T'HONE/ ]^ SGYJ 7C_1V kvl j ec dr%L- i CONTRACTOR SIRE i fY �p�7^ .S[2ti-f�,..wax_.��0$�r .�'C-T�.�sdl�= - ADDRESS Allam .r..Jf l� n 9c1F=P u',LL1CIT,PNONI: 42 1,07 ALIS CONTRACTOR I . I 5.4 )j!-, - xA/C ADOWSS. 4L � c L GW__UCO I,@0 IQ PHONE+_232-7_5 ZS TYPE OF WELL 10.FP: NEW WELL O REPLACEMENT WELL ❑ MONITOR"WELL A OMALLATPON ❑ WELL SYSTEM AEPAIR ❑ CROS"ONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J_ 13New❑ UMP AepeY H.P._ DEPTH PBET FT, FIRST WATER LEVEL O HYPE OF PUMP) 1 ❑ OUT-OF-SERVICE WELL 11 GEOPHYSICAL WELL 6 (3 BOIL FORM S i ❑DESTRUCTION-. INT EO US Tylm O n� CONS-TRUC TfON S!!Lc wAtTIDNS A ❑ NDUSTa1AL ❑OPEN BOTTOM LMA.OF WELL EXCAVATION L, �N DIA.OF CONDUCTOR CASINO J9 D ❑ DOMESTICIPRTVATE GRAVEL PACKISRf_,ZIi J TYPT OF CABIHOfS7EEl1PVc .5 .k jy[�_ DIA.OF WELL CASINO_ _ L s +F __ p ❑ PU IM ATUWIPAL ❑DRIVEN 'T- DEPTH OF GROUT BEAL SPECIFPCATIOH ❑ "UNGATIC"AG ❑0THM GROUT SEAL INSTALLED eY�.=ariw.-•t ��1 GROUT BRAND NAME E VMONITORING GROUT SEAL PUMPED: W Yr -_ _ _ CORIC$TE PEDESTAL 8Y yO.PELLER. YM 0. 5 {� APPROX.DEPTH__ 2! �t�� ^ LOCI-NG CHEATER BOXMTOVE PIPE��- A/IFLiGc� ��%:r ►7 S 't PROPOSED CONSTRUCTTONIOIRERNO METHOD; MUD ROTARY AIA ROTARY" AUGER__CABLE OTHER 44:s,r-J., 1 �� t.11 I FIMSY CERTIFY THAT t HAVE PREPARED TMS APPLICATION ANO TNAT THE WOW WILL DE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND�1 IMGULATI(M OF THE SAN JOAGIARI COUNTY, HOME OWNER OR LICENSED AGENT'S WRATURE CENTIFIEf THE FOLLOWING!'I CERTIFY THAT N THE PEFW40MAAPICE OF THE WORK FOR VHICN TWO PEMMY 19 ISSUED,I SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMMSATWN LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR 1111.1"ONTRACTNG SgHATUtE CERTIFIES THE FOLLOIMNO_ 'I CfRTIFY THAT N THE PFINFORIAMiCE OF THE WORK FOR%%%Wil THIS PERMIT NS IASUED,1 SHALL EMPLOY PERSONS SUBJECT TO WONSMIAIT'S COMPENIATNIN LAWS OF CALIFORNIA.' T APPLICANT MUST CALL RI AVVANCS FOR ALL REOWARfD INSPECTIONS AT Z2W/06.74!7. COMPLETE DFIAWNG AT LOWER AREA PWVIOED. SPp+ed x Ttth 'rrL.l�tT� - Ort "1 V PLOT RAN @New to Bede)90.10 •Ie 1. NAMES OF BTRIEETS OR ROADS NEAREST TO OR BOUNDM TILE PROPERTY. /. LOCATION OF HOVSE SEWAGE DISPOSAL SYSTEM OA PR f"ffEO I. OUTLM Of THE PROPERTY,OIVIM DIMERIMONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL*YSfEMS. 7. bIMEHSkYWO OUTLNFB ARU LOCATION OF ALL EXISTING AND PAOPOSFD S. LOCATION(if WELM HRT111H RADIUS OF ONE NLUMWD FIFTY FT. STRUCTURE@,NCLUDNG COVERED AREAS SUCH AS PATIOS,D1tjVEWAY8,AND WALKS_ CNV THE PROPERTY OR ADJOIJIID PROPEKTY, GVARTMEHT USE ONLY AppMellan Awspled'by �; Oeh d � MY Opsin IMpeacia"eye ,}4!! i!' Date 1 ZJ6cl` PL—F lnepeetlen BY "note Deetroellsn hwpeetlen ST Data CaNnmenls: ACCOUNIINU ONLY: AID/ FACE R E/CODFEF Iwo AMOUNT R"TTEO C fCASH RECINVEO MY DAT //ERVFeE REOLIO6T NUMB MIVOIC7 � Sa , oa Q Zs =p A _ - Pub Heaktl Serv.-ErMFO, 173(1197)