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APPLICATION FOR VVELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION V 0 BOX 3178, 446 N.SAN JOAQUIN ST„ STOCKTON,CA 9b4ul-388 (109)4683410 NGR!EFUMDA6iE PFRMIT EXPIRES I YEAR FROM DATE ISSUED Wamplefa In Ttpliatal _--- APRICATION 16 HEIIE NY MADE 10 TIIE SAN JOA.)UIN C'PON'Y INII A ITIiM1i ID CONSTm,CI ANI/[)R INSTALL THE WORK INSCRIB(U THIS AP'LIC AT ION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY Of%tIOPMINT TIT IF.CIIAPTfP 9-1115.3 ANI.THE STANOAWL)G") If SAN JOAOUIN COUNTY Pill PITA:TH SERVICES.INVIRONMt NTAL HEALTH DIVISION. 7 JOB ADURFSWF4 AR'FN. / •��' ,'f'W IA_ �l I V 1C 11Tv � I r 1 PARCFL 1/APNI UWNEfl'5 NAME. AIN1Rf 66��J CI!NTMCTOfl - L 3}f '1`-AUDN(66 �I k '1 LICA AIONf I J , OUB CGNfRR•ACTOR� _ ADUR)S6 �f LIC/ R10NE 0 TVPf 0' VFIL/PUMP. ❑NEW WEtL ❑ -011ACEMINT WILL LJ MONITONNO WE LL 1 ❑OTHER ❑ - INSTALIATION C3 _VTI1SYSIFM ALPAIR 13 CROSS CO:NNt CT REPTA.IR ❑VAPOR EXTMCTIO'N WELL$, ❑ FIRST WATER IEVEL O (TYPE OF PUMPI ((A ,) ❑CUT OF-6ERVICF WELL ❑GEOPHYSICAL WELL S ❑ SOIL SORING B INTENDED USE TYPE OF WELL CONSTRUCTION LPECIFICATIONB I A y ❑INDUSTRIAL ❑OPEN BOTTOM 01A.OF WELL EXCAVATION INA.OF CONDUCTOR CASING___ 0 R\, XWVE:TIC,7"VATE ❑ORAVFt PACK/SIZE TYPE OF CASINGISTEFLPVC DIA.OF WELL CASINO_ D ❑PUSUC/MUFIICIPAL ❑DRIVEN DEPTH OF GROUT DEAL_ SPECIFICATION q �.a ❑IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GN)UT BRAND NAME E ❑MONITORING GROUT SEAL PV'1PfD.❑Vr ❑N. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑N. S APPROX.DEPTH LOCKING CHESTER SOX'STOVE PIPE S PROPOSED CONSTRUSTION/DNWNG METHOD: MUD ROTARY AIR ROTARY_ AUGER CABLE_ OTHFF . _ 1 HEREBY CERTIFY THAT 1 PAVE PREPARED THIS APPx^ATION AND THAT THE WOW WILL BE DONE IN ACCOROAFrCE WITH SAN JOADUIN COJNTY ORDINANCES.61 ATE 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 F09 WHICH THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY rfR60N0 SUBJECT TO WORKMAN'&COMPFWSAT10N LAWS OF CAUFORNIA.'CONTRACTOR'S HIRING OR SU9-CONTRAC Ahn SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FnR 1•AIICH TM 16 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEWATION LAWS OF CAJJWRM TPD!')tPPUCANT MUST CALL S4 RO IN ADYANC FOR ALL REQUIRED t AT 10&1 tHy &17. COMPLETE DRAWING AT LOWER AREA PgIOEp. / KHP-d X ROT PLAN IDr to Se.l.l Sub 'to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCAT OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED t.OUTLINE OF THF PROPERTY,OMNO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DtSrk M CYSTEMS. 3. INMENWNED GUTUNFS AND LOCATION OF ALL EXISTING AND PRC'OSED S. LOCATION OF WELLS MTHIN RADIUS OF nNE HJNORED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DFJVLWAYS,ANC WALXS. ON TIIE PROPERTY OR ADJOINING PROPERTY. � - o _ DEPARTMENT USE ONLY " APPIb.1bR Aro.plr BY G-A 1—1—BY 1 D. 14mP IMDecHl.n OY D.Hncn.n 1-0-0—BY D.1. ACCOUNTING ONLY: AIDJ J'' FAC. —� 11 CODES ,/� AMOUNT REMITTED 4yF ./AASH RECEIVED BY /DATE I.T4��T/_SJJJ.11.1 REGUE.•NWa91 INVO)C��