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' APPLICATION FOR WELLJPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 396,446 N SAN!, UIN ST,STOCKTON CA 96201 386 f2U_ b83420 RON REFUNDABLE PERMIT FAHRES 1 YEAR FROM BATE ISSUER ILEmpIItE In TIiIBptEk ' APPLICATION IB HEM BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR 1NSFALL THE WORK DFBCRIOEO THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 8 11U1�15 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC`'HEALTH SERVICES ENVIRONMENTAL WEALTH DIVISION JOB ADDIIESMA pAPN,,F L"^ E q,1 E� o.I-�5 �i--'?.t'-t.�`CET.,j 5}q�.A(-k- �I PARCEL GUEJHNI a OWNER I NAME_S.A_1y_ t Sioc.V+01`1 L t _l_ADDRESS +L4(95_Sf,�4\n�1/✓�E S�1/�-4r�L PHONE P�1 '13 q1-9,43 CJ CONTRACTOR SLN t CA")k faAR-L.Ik-Q 1 Tf-"' KJ ADORL6S I-Llp C7 Cr✓4p IlY IS i11A UC/ O�1 Q-\ PHONE I 2� 1 !9-t j 2 221 ' wacoNTRAcT*Fi rAkk l!% _ -ADDRESS L ON AL `-1 �I.(S�1ZtakY PNONEILI� 4tIS-4S {2 TYPE OF WELIMILIP. ❑NEW WELL ❑REPLACEMENT WELL ❑MONITOIIINQ WELL/ ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL 0 J 1314—❑PAP& N P DEPTH RUMP SET_FT FIRST WATER LEVEL O /TYPE OF PUMP1 ❑OUT-OF SERVICE WELL ❑GEOPHYSICAL WELL I ❑ SOIL BORING 0 �DEBFAAICTON N O O W CONSTRUCTION SPECIFICATIONS I A ' ❑INDUSTRIAL ❑OPEN BOTTOM OLA OF WELL EXCAVATION o/ CIA OF CONDUCTOR CASINO f-!T O IM ❑DOMEBTIC/PNVATE ❑GRAVEL PACKYE TYPE OF CASING/STEEl pVC l+ IMA OF WELL CASING ❑PIBLICIMUNICIPAL 13DRIVEN DEPTH OF GROUT SFAL ze SPECIFICATION (-yN I-I +_ N ❑I ATIONIAG ❑OTHER GROUT SEAL INSTALLED BY t,G.lata L�O f aRGUT BR ANo NAME C YYr..Lt L1,aFaalr�I-- MONITORING I aROUT SEAL PIMPED Iy Ys ❑Ne CONCRETE PEDESTAL BY DJILLFR❑Y- S ' APPROM DEPTH LOCKNO CHESTER SONBTOVE PIPE 5 PMPOSM CONSTAUCTIONINEWNG METHOD MUD ROTARY AIR ROTARY AUGERX_CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT TOE WOR[WILL BE DONE N ACCORDANCE WITH IMV JOAOUN COUNTY ORDINANCES STATE LAWS AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY NOW OWNER OR LICENSED AGENT I SIGNATURE CERTIFIES THE FOUOSMHO I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHCH ' THIS PERMIT 19188UED I WALL NOT EMPLOY PERSONI SUBJECT TO WORIKMAN E COMPENSATION LAWS OF CALIFORNIA CONTRACTOR S HNNG OR SUBCONTWACTING SI NATURE CERTIFIES THE FOLLOYANG 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERAST R ISSUED I WALL EMPLOY FERBONS SUBJECT TO WORKMAN S COMKNSATION LAWS OF CALIFORNIA THE APPLICANT MUST CALL as �AW6 FOR ALL REQUIRED INEPECTIONS AT 120914SRa.]1 COMPLETE DRAWNG AT LOWER AREA PROVIDED BWO.d% �/1/1.1� TIIM �J I/p �T�`11rL,Fr l O4NAL� 1_c T PLAN(M—M R..1.)B..4le JAI Y ATT QL.� 6O t kci^ ' 1NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPO IED 2GIVINGNRE E OUTLINE OF THE PROPERTY GIVING DIMENSEAND FORTH DIRECTION EAPANIIDII OF OKWAQE DISPOSAL SYSTEMS .1 DIMENSIONED OUTXI LINES AND LOCATION OF ALL ESTIIIO AND PROPOSED E LOCATON OF WPAS WITHIN RADIUS OF ONE HUNDRED FIFTY FT STRUCTURES INCLUDING COVERED AIEIUS SLIDH Ai PATIOS DRIVEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY 4 Ed b 7 I eAv «J EN1PwC[ � m SOEnyK 11 r- r-1 I r-�� del BJs NYs er. !S U1G STfIPM LwrAI L GEND ' '", MOWGRNG WELL RI/1 SOIL SAMPLE (6/9/86) SITE PLAIT SHUWIHG PRODUCT LSIES TRENCH SOIL SAMFPI E LOCATIOIJS - — - VAPOR RECOVERY PIPE STOCKTOt$ POLICE STArim STOCKTON CALIFORIIIA OIPARTMENT LME ONLY Apalle.Ion A.o pOW If 0.1. A— a—In.P.0-BY D.K. Pune WN flun By OV. ' D-l—Lk n E.p.e0.n 8Y D.. C—i. ACCOUNTING ONLY AIDP FACT PS CODER FIX INFO AMOUNT REMITTED CIIEGKIK`ASH MaVEL SY DATE P6wpT1491N6[REQUEST NLIASBL INVOICE 1