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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES DEC Z 7 "=9� ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TTIpReml APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A IERNST TO CONSTRUCT AROMA INSTALL THE WOR(DESCRIBED.7III9 APPLICATION 18 MADE IN COMPLIANCE WHIT SAN JOAQUIN COUNTY DEVELOPMENT Yl TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PPURLIC HEALT11 SERVICES,ENVIRONMENTAL HEALTH DIVISIION.N./ tI{' aOIA.CL�.�A,� �Q .�-'-L.-O q ` CITY /,/F-//lG� PARCEL S12E/APNI JOB ADDRESSMR A✓✓PN/�I.$60 ' 5S'/�./ {/�(�/(��//y�/� //Ah /+ /J �y /�X AL1,�( / Q OWNER'S NAME'yy�11^(/��S�' ,406�y�•/e� ��EIbt (f4WA OGRESS /I��1Wj G iecrH/W Vy D6' �'-02$ PHONEI CONTRACTOR IVFV/A►1 IUM r`�F111�IY14 AODPESBIV/ oL L R141,Lc L1CI ybl, PIONEI C��yJ, /' r�+r-. I `' C i UC11551 w PIONE I :ip(� SUSCONTRACTOR 60(?A EC ZK&i(INC~ A00(1E88 TYPE OF WELUPUMP• ,O NEW WELL FBL REPLACEMENT WELL ❑ MONITORNU WELL I�j14W( ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS.CONNECT REPAIR ekes/ ❑ VAPOR EXTRACTION WELL I ✓ ❑Nwv❑RMP, NP. _ DEPTH NMP SU—FT. +(IIE� ART WATER LEVEL O (TYPE OF PoMPISOIL ROBING R ❑ OUTOFSERVICE WELL ❑ GEOPHYSICAL WELL I — ❑DESTRUCTION: A [OUSE TYPE OF WFLL -CONSTRUCTION SPECIFICATIONS/�/f,� FI ❑ INDUFUSAL ❑A-�OPEN BOTTOM CIA.OF WELL EXCAVATION /0 I0-Iz DIA.OF WELLCONCASINGUCTOR IPO O ❑ DOMESTICIPRVATE Rit dUVR PACKIBTZE TYPE OF CASINGISTEEIiPVC GIA.OF WFIt CASINO O ❑ PUBLJC/MUHgmAL DISVEN DEPTH OF GROUT SEAL CS SPECIFICATION R ❑ IRBIOAigN/AO ❑OTHER GROUT SEAL INSTALLED BY Ek'E�-�' GROUT BRAND NAME E MONITORING ,�nn�/ /f,'y../nI //�((n/L GROUT SEAL PUMPED: idY. ❑Ne CONCRETE PEfH:BTAL BY DRILLER:❑Yw ON. 5 APP X.DEPTH �` �� •��,r"I' r-u•T Al LOCKING LOCKING CNEQTER BO%/STOVE RIFF 5 PROPOSED CON.TRVCTONIORIWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPL1CATgN ANO THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY OMINAHCES.STATE LAWS,AND RULES AND F THE SAN JOADIIM COUNTY- HOME OWNER OR LICPENENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'1 CERTIFY THAT IN THE PEREORMANCE OF THE WOR(FOR WHICH REGIAATIONS OHE S m1ALL NOT EMPLOY PERSONS"ACT TO WORKMAN'S LAWS OF CALIFORNIA.' IRING A.' CONTRACTOR'S OR BN"ONTAACTIM SIGNATURE CERTIFIES THIS PERMIT IS F T THE F0110WING: -I CERTIFY THAT m THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY MRSON8 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORMA.- TH PMCANT M �1/1//;�//U/RJ IN ADVANCE FOR ALL REd11RfD 1 RCST TIONS AT X11O.J��11449 S'1". COMPLETE DRAWING AT LOWER AMA PR "CfO.J u/w`s'L /K/NFCNA(�l TIB.�aGXKL`-/ IL'/CC% �A�L �"]"1 swT X� '716-55 / 5-7 1,42- ROT PIAN q,ew to R W-1 Rn.le 'le o 'I SYSTEMS f. LOCATION OF HOUSE SEWAGE SSYSTEM OR AbPoBED 1. NAMES OF STREETS OR MADS NEAREST TO OR BOVNdNO THE PROPERLY. EXPANSION OF SEWAGE dePoBAL SY8TETEM8. !. OUTLINE OF THE PIIGPERTY.OV NG DIMENSIONS AND NORTH DIRECMN. S. LOCATION OF WELLS WOHNIN dVFTY RAB OF ONE HUNDRED FIn 9. DIMENSIONED OUQUNFS AND LOCAM"OF ALL EXISTING ANO PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY- STRUCTURES.OICLUNM COVERED AREAS SUCN AS PATIOS,DRIVEWAYS,ANO WALKS. ETIeHED lN�FK P��✓ /1 AI Al177 _LEl�� Cts//s1�11 � ooftA-'�Irq- 50icova-b 2 CWF 99 Aft"A'j L11 Qpn/n4t75 R OF 44rWJ? - 1<eA/ 13"IK L.yvN A�e�,�Y yrv�zgPJ�ov;_ ,pd✓ FAv9t'- �s-5y3-55i r:�,� rr.�D �-wMT/.vrr � Ei4S�i�t�NT �cyu[SIT7o�/ ,yiv 5.29 B, c,D (Sb ACA ti'°E9�A�`8� i ) E}�E r Nor /C, 5ci I / I e W,*PAC- 0A1 4y&1Aa&4#41A'WW ZvrAkir-, V�D CBM �rr� s pb�zrY� DVMTMMT VSE ONLY NPL APPIIeelbn AaeMlad BY 2H7C D.b / Mw Groin Impetllen BF � O.0 RmsImPMBen BY D.1. O,nbacBen Iwnecllm BY D.b Y7tAJ S3� S� /y A ACCOUNi1NO ONLY: D/ FACT PE CODE. FEE INFO AMOUNT REMITTED CHE I AEN RECEIVED BY DATE PERMIT/SERVICE REQUEST NIe M INVOICE oI S D° 6g 7383 Da 6 �D