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°PLICATION FOR WELL/PUMP PERMI SANWOUIN COUNTY'PUBLIC HEALTH SE*S ENVIRONMENTAL HEALTH DIVISION 111 304 EAST WEBER AVENUE, STOCKTON, CA 95202 ORIGINAL • (209) 468-3420 NOM.REFUNOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Trlplieeb) APPLICATION IS HERE By MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMn INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE MN SAN JOAGUIN COUNTY DEVELOPMENT TITLF.CHAPTER 91115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC(HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. �J // n / (� // B.rt� JOB ADDRESSroR AMIJ7-/7 F i U W l �jre CITY —2io hM PARCEL SIZEIAPNt Q SLi /90o powellI OWNER'S NAME C/o --Iri �/"� tw.Ceni.+t-F�:.Vie- /ZPeR.J ADDRESS Evne��uJ/�fY l'R' 95'Go8 AIONEP o F5.7'YSOO CONTRACTOR ADDRESS Me PHONE I � // l/ //3S0 Howler r{.�ee SUR CONTRACTOR Trn AJScLYOpaR,)ZAIi/R.l mfi—y( w7 Psn T}Z((y ADDRESS Ro� /+D O/'d,ac l,'.Q UC# 70GS4S RHONE/2/{ 9 -170/0 9S7S�2 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ✓ ❑New❑RPP-Ir H.P. OEM"PUMP SET—FT. FIRST WATER LEVEL O HYPE OF PUMP) IHR�S( ❑ OUT-OF-SERVICE WELL 13 GEOPHYSICAL WELL# l4 601[BONNG B 13DESTRUCTION: ,3-iS QO rtNQ v/—SYQL.{fTe GU/A46 J 7 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL ❑OPNBOTTOM DIA.OF WELL EXCAVATION —1j" DIA.OF CONDUCTOR CASING N/Q. O ❑ DOMESTIC"IVATE 11 GRAVEL PACKISRE TYPE OF CA61NOISTEELANC /J/0. DIA.OF WELL CASINO 0 ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL TD><a/ DP6R�1 SPECIFICATION (16MA1,74 R ❑ IMIGATIONIAU ❑OTHER GROUT SEAL INSTALLEDI�SEY jtj-�PY SMUT BRAND NAME A)/--L E ❑ MONITORING 0 GROUT SEAL PUMPED: W Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr RN. 5 APPROX.DEPTH SOT LOCKING CIHESTEn BOXISTOW RPE / 5 PROPOSED CONSTRUCTIONRNeIUNU METIHOM MUD ROTARY AIR ROTARY AUGER CABLE OTHER,Q/ Du jA 1 HEREBY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1614ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOTWIA.' CONTRACTOR'B HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWINO: -1 CERTIFY THAT IN TIIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.- THE APPLICANT MUST LL Z4 HOURS IN ADVANCE FOR ALL Y..yR�"E�/OOUNREEDD INSPECTIONS AT(M j 4H04B8. COMPLETE DR WING AT LOWER AREA PROVIDED. 610-1X r� /Y1 • / V/� Aill X. � ;R V/TI!P,J D.I. /4/n. '/ PLOT PLAN 0—le eadel Sad- 'le / 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE POVERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR MOTO EO i. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIDECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. Mi4p e �- I' DEPARTMENT USE ONLY f //CJ M.. D I FY/'/ APP0ee11on Aearyled BY G. 6 d(,//X/� O.ovl Inefee6on BY MI.—Pur p I..Peallan By DM. U..�.mKlen I,..nea6on By o•1• Damn,n,l.� 6y7-� 662 —ZZ ^L✓ ACCOUNTING ONLY: AID# FAC/ PE CODES FEEHNFO AMOUNT REMITTED CHECKSMASH BY DAE I PERMIT/SERVICE MODEST NUMBER INVOICE qo :513 I 1 Oi�300 Pub.Health SEN.-Enviro.173(1/97)