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APPLICATION FOR WELLIPIIMP PERMIT S .IOAQIIIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P.O. BOX 368. 304 EAST WEBER AVENUE, STOCKTON, CA 95241,,188 (109) 468.3420 N0N•REFUNDABLE PERM T EXPIRES 1 YEAR FROM DATE ISSUED ICampittr IR TripGeata} APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOFK DESCRIBED,THIS APPUCATION 18 MAD£IN COMPUANCE NRTH.SAN JOAQUIN COUNTY DEVELOPMENT TM.F `CH,APT(ERR 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERIRCEB.ENIRRONMEKTAL HEALTH pM610N. JOB ADOREe&OR ARLVI��g O t.•+ C�j� _ Na PARCEL BrZ�E/A_PNs crTY {� � ��a 1 CA �fi3� n I CWNER'S NAME ��., f ot.Q}T, l) . ADDIti'15 t°I, 1_ PHONE s�3 CONTRACTOR P\ja c GV L`Oj�C�`1 'Y _ADORES y I r , !-��y� J. 4 r LPCr ,Pt•M►•IE I SUB CaHTRAC7AR�. C3,f „ � � ADORE � 1C Iy 1 SONE I �] TYPE OF WELIJPUMP- ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I © OTHER ❑ INSTALLATION ❑ wELL SYSTEM REPNR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r J (TYPE OF PUMP) �•._ 13 New EDRepdr H.P. } DEPTH PUMP SET FT. FIRST WATER LEVEL` _ O 'fit/1 13DUT-0E-SERVICE WELL © GEOPHY8tCm..ELL tl.I SOBORIIKI 8 K��pfSTRUCTION; o k`AL +6 (k r—t' c-- WELL � - INTENDED USE TYPE OF W CONSTRUCTION tPEC1RCAT10NS A INDUSTRIAL ❑OPEN BOTTOM DIA-OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p J DOMEBTIC/PLIVATE ❑GRAVEL PAC umr TYPE OF CASINOISTEELPVC OIA.OF WELL CASINO D PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF OROUT SEAL SPECIFICATION R i 1RRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E i R)RONTTORING GROUT SEAL PUMPED: ❑Yr ❑No CONCRETE PEDESTAL BY DRILLER❑Yr ❑Na S lkppmx DEPTH LOCKING CHESTER BOJUBTOVE PPE 3 'siOPOSED CONtTRUCT'IgN1DWLLNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER HMBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES ANO >ECULAri0N8 OF THE SAN JOAQUIN COUNTY, HOME OWNER OR 110ENSEO AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:7 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH i -HIS PERMIT IS 188UED,I NOT EMPLOY PERSONS SUBJECT TO WORKTMAN'i COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTIHG SIGNATURE CERTIFIES 'HE FOLLOWING: 'I THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMArI't COMpmeATION LAWS OF i :ALIFOPMA.' MUST CALL 24 HOUR&RI ADVANCE FOR ALL REQUIRED INtPECT10Ni AT r NW)449 7-427. COMPLETE DRAWING AT LOWER AREA/(PR VIDED. 3grwd X Tltte q«. b PAT PLAN Meow to 8wI.I god" `to NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY,GIVING DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S- LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.' STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, � e •. ` ...fir ;.. ._..__.;.....:...........................:.................................=.......:... .. ...... .. .. . .... : PA ....... ............:....................:......n.....:......:....................;..... ,..-. .. .. .. �X1CRE�7`.. � RE• O1 D v . . .... ... . . - � � JULIO 7 799 .....,.. ..:.....<,..: •�- � I SAN JOAI]UIN COUNTY DEPAPITMOIT USE ONLY PUBLIC HEALTH SERVICES 1 ENVi ONME AL HEALTH DIVISION ( f apYeatlen Aaaepted BT Oets A--____L—I — „t,t"Pe lwm By Onto PLm In.peetlan By Dots ,n.vetlor,h.P.etl«+BY �"� ��-^ � .�.•_ Det. 22 , arnnw'Rt: V . ACCOUNTING ONLY: AIDS FAG PE CDDES FEE INFO AMOUNT REMITTED CHECKSICASH RECEIVED BY DATE PRMITISERVICE NEO T NUMB OR INVOICE JS V 1 h