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APPLICATION FOR WELLIPUMP PERMIT ,-: '—�-- SAN JOAOUIN COUNTY PUBLIC HEALTH SERYIC7- ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AANUE.STOCKTON. CA 85201388 (2091 468-3420 _ - mail-AEFIINO'ABIE PEAIMIrEJlPigm 1 YEAR FROM BATE ISSUED (Campi.th fn'Trbficwel APPLICATION 08 HERE BY MADE TO THE SAN JOADUIN COUNTY FOR A PERMIT TO CONSTRUCT AN01011 INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WWII SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. C -�7AC42ES JOB ADDRESSlOR APNf 6 f CITU S.ej C h re PARCELrt MZE/APN/ OWNER'S NAME_ L.i� L"'71 L t?-GagLIC i S Cy, � ADOR£ss ' .q 13" r pvG FHow a CONTRACTOR _S- �' i,4 T�^1.I.St}AlA�'1��.lNtZ._--i>'f I-�•T� ADDRESS 2-70 P4_eICLAJS S!.�LICs reroNel37 —05Z are CONTRACTOR 4IZI_L•Lt"t7— -int nli�— ADnRESR� i�cJ in .L' kbSi(e5"nroNE�Srr773i�S-3"Fccc TYPE OF.WELUPUMP- © NEW WELL ❑-REPLACEMENT WELL ❑ MONITORING WELL i ❑ OTHER 0 INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL It J [3New❑P.& H.P. DEPTH PUMP SET FT-1 FIRST WATER LEVEL O RYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ OEOPHYBICAL WELL ff Ii¢ SOIL SOMNO ❑DESTRUCTION! INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL El OPEN BOTTOM CIA.OF WELL EXCAVATION DIA,OF CONOVCTORCASMO O ❑ DOMESTICMMVATE' Cl GRAVEL PACK/BRE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASINO p ❑ PUBUCIMUMCtPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION .. - q ❑ IRRIGATIONlAG - ❑OTHEq GROUT SEAL INSTALLED.By GROUT BRAND NAME : E ❑ MOWTORINQ GROUT SEAL PUMPED-. ❑Y. ❑Nn CONCRETE PEDESTAL SY DRILLER-0 Y.. ONO S APPROX.DEPTH LOCKING CHESTER BOXfSTOVE PIPE - ., S PROPOSED CON6TRUCTIO"[DRILLINO METHOD., MUD ROTARY AIR ROTARY AUGER CABLE OTHER auz a 114MIlY CERTIFY THAT t HAVE PREPARED TMS APPLICATION AND THAT THE WOR(WALL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. IEOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE F-OLLOWRM,'1 CERTIFY THAT IN THE PERIORMANCE OF THE WOIR FOR WHICH THIS PERNOT IS ISSUED,1914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEW%ATION:LAWS OF CALIFORNfA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I ERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMfT IS ISSUED.I SHALL£MPLOY PERSONS SUBJECT TO WORWAAIH'•COMPp06ATION LAWS'OF CALIFO f ANT Al;21}HDUIt!IN ADVANCE FOR AL1.REQU111Eb J.IjN6eECT1ONi AT 12��0++sl��s66y12f. COMPLETE DRAWING AT LOWER Aq£A PROVIpEb. sh""d X PA.. [` � CJ�G� 7 Sj' Dns ��'s`y�•� 'PLOT PLAN IDtsw Is Saslwl Re.lw� 'to 1. NAMES OF STf1EET8 OR ROADS NEAREST TO OR BOUN1MtG THE PROPERTY. 4. LOCATION OFHOVBE SEWAGE DISPOSAL SYSTEM OR 2. OUTpROP08E4 LINE OF THE PROPERTY,GIVINp DIMENWONR ANQ NORTH bFREC7ION• EXPAHBfON OF SEWAGE bIRPOBAL 9YSTEMR. - 3. bIMENSIDNEQ OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HVNOMID FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPEM On ADJOINING ... - FE ...... S �. . ........s . ... ..... _... .. Tr - p ' M• F t " _:.... ........... ��'• ..................... ....... DEPARTMENT USE ONLY Dns Pt—v U»psetl n BY bsh . Enepm k., . Oats ACCOUNTM ONLY- AIDI FACJ rig cx"OEa FEE INFO AMOUNT REMITTED CHECK/lCASN gECOVED BY DATE P901MTl6g11ACE REQUEST NUMBER INVOICE 35o ti 2-3 DE Pub-HeaEth Secy.-envifo.173(3196)