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I _ Y • -•..ntfuIN PUN wtLLIPUMP PERMIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVwIr,Ft L ENVIRONMENTAL HEALTH DIVISION PAYMENT P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 95201-388 A/ 0269) 4x8.3420 f�E$E I VE D i �S _ K►��Ft7e�. �C� I�� 37-01 SLU NONREFUNDABLE PERMlT'EXPIRES 1 YEAR FROM DATE ISSUED SAID! .:LI,��I_IIti {;C,I�dTY APPLICATION IS HERE BY ADE TO THE SAN JOAQUIN COUNTY FOR A PEPoHtT TO CONSTFIUCT AND/QR INSTALL THE WORK DESCRIBED.T PUBLIC HEALTH SER':ICES L JOAQUIN COUNTY DEVEL ENT TfTLE,CHAPTER 9-1116.3 AND TH£ST ARD OF JOAOVIN COUNTY pUB1-IC 1{EALTyt SERVICES.ENVIRONnMENTA�L��H7EA(LT�H[pI�V�IS7IO�NJ.'}��1�(�(�� �I�++r�ctt','t5�At7e MfL`UpLfApC£WRF!SAN J6B•�°�Tt[7S/0R . -Z — D S R CITY _1 0 cTV N ]. ' ES 1 _PARC SUE/APNI 5, �Q[, �� OWNER'S NAME ` +�.VG CV7 I F- F Q- CONTRACTOR 1` 1 N�-'E _ -./AbpFtESS BG5�S S t WF•1 cr-. lJi [ LU 7 7�/�/ � � '' 7 - PHONE S- {�-� ADDRESS-2 z 11 ~ I/Vkk SUS CONTRACTOR CE,r .YY L 3.� J' PHONE• �;I� j �/� i � 'fes ADDRESS s W iI1Ki1YI S'� rS7 PHONE f �� 2 TYPE OF WELL/PUMP: NEW WELL ❑ REPLACEMEM'WELL ❑ INSTALLATFOIJ ❑ WELL SYSTEM REPAIA ONFTOPoNG WELL S �ij ❑ OTHER ©;CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL S Cl Naw 11Repalr - .? J ( SOIL BORINGTYPE OF PUMPI HP.�^- �'' DEPTH PUMP SETS FT. FIRST WATER LEVEL WELL ❑ OUT-OF-SERVICEO . ❑CtEOPHYSICgL WELL S ❑ LoDESTRUCTION: B ' t INTENDED USE TYPE OF WELL !p CORSTRUCTIONSPECIFICATIONS 7 INDUSTRIAL ❑OPEN BOTTOM i .� .� // �� : + r► A DOMESTIC/PPoVATE GRAVEL PACKISQE 0 52j��OiA,OF WELL EICCAYATION o,A.OF CONDUCTOR CASING N JT .TYPE OF CASINGlSTEEUPVC � �' L7 PUBUCIMUNIClPgL El Dm I:DEPTH OF GROUT SEAL_ �ijZ - �A OF WELL CASING �I D IRRIGATION/gG '4 SPECIFICATION '1 ❑OTHER 'GROUT SEAL INSTALLED BY R MONITORING �I QN�rn 1�- GROUT BRAND NAME GROUT SEAL PUMPED: ❑No E APPROX.bEPTH_`�C] Yee - CONC"PEDESTAL BYhWLLE ❑No �� i R;❑Yw S "OPOSED CONSTRUCTfON/DRILLING METHOD: MUD ROTARY IOCIGNG CHESTER BOX/STOVE ppE AIR ROTARY. S AUGER`CABLE OTHER - HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL IBE DONE IN ACCOPo)ANCE WITH SAN JOAQUIN COUNTY ORbINANCf6,STATE LAWS,AND RUMS AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING;9 CERTIFY THAT!N THE PERFORMANCE E THE WORK FOA WHICH THIS PERMIT f Eb,I SHALL N07 EMPLOY PERSONS SVBJfCT TO WNE FOLIOHG; I RT THAT THE PERF{)RM RKMAN�S COMPENiATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIPoNG ORSUBCONTRACTING SIGNATURE,CERTIFIES ALIFORM, CE OF THE FOR WHICHTHISPERMIT16 ISSUED.I SHALL EMPLOYPERSONS SUBJECT TOWbR10MANiCOMPfNSAT10N lAWB DF C M MHO ADVANCE ALL REO IAREp fIIIiPgCTiONi AT[20SI sei3tz3, COMPLETE DRAWING AT LOWER AREA PROVIDED. slQned x Tithe_ NAMES OF STREETS O ROADS N PLOT R a .to scale?ScaN ;` - •1O - iiiggg��OUTLINE OF THE ORO NEAREST TO OR BOUNDING THE PROPERTY, 3. DIMENSIONED OUTLINES ANDOL.00NATIONEOF ALL FX,STTN�G�AHDIRECTION. PROPOSED 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM OR PROPI EXPANSION OF SEWAGE DISPOSAL SYSTEMS. STRUCTURES,INCLUDING C VERED AREAS SUCH A6 PATIOS,DPoVEWAYS,AND WALKS.'I � S. HUNDRED .:......:.. ...:. FI , 6 LOCATION OF WELLS Uq'TI{Iry RADIUS OF ONE HE PROPERTY OR ADJOINING PROPERTY. dk. _.. a DEPARTMENT USE ONLY - APPllcation Accepted By Irrpectlon By Dete_ L Area Date _Pump 1 peatbn By L •uctlon Inepectinn By ! Date Comrnentr Q>Ufrc if4G�J, Date t. ACCOUNTINO ONLY: AIW _ FACS ,a k ' � + : CODES FEE INFO AMOUNT REMn-n p CHECKS/CASH .,., . RECBVED BY DATE Pt3tIWT/S13t C'E REQUEST Ntaftim INVOICE b 'aDCS FS5 ,� 7—f 9�