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' a � APPLICATION FOR WEWPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 1011-REFUNDABLE PERMIT EXPIR S T TEAR FROM DATE ISSUED IGRrA6LM iN TrbRal"l APPLICATION IS HERE SY mAot TO THE CAN JOAOUN COUMY FOR A PERMIT TO CONSTRUCT ANDAR INetALL THE WORK LIESCRIBEO.TIG9 APPLICATION IS MME IN COMPLIANCE WRIT SAN JOAaVIN COUNTY OEVELOF7JENT TITLE.CHAPTER AIM THE nTANOMOE OF MAN JOAO"COUNTY PUBLIC HEALTH FLITME9,ENVIRONMENTAL HEALTH orvimo N. Joe AOD/ESMAMR APNF S CG f 61N 90AJ CITY mckw V PARCEL MZFJAPNF OWNER-SHAME T ADDRESS .545$ Set_hGrJ PLOA tj 1, ' ` r ' PRONE: �,o CONTRACTOR J1f' L ADDRESS 05 N,W11SpIJ W UCF $02� !y71PHONE.+67—�OOIo SUn CONTRACTOR ADORrtMe 67 LICF PHONES BL613 LZZ. TYP�OF WEU#VMR ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL F ❑O"a - I ❑INUtALLATION ❑WELL SYSTEM AFFAIR ❑C110610-CONNECT REPAIR ❑VAPOR EXTRACTION WELL F IJ ❑Nrn I7 RtpNr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O RYPE OF PUMIT � . ❑oUT-0VIC F-REAE WELL ElOEOPI YSICAL WELL F P'SoR"OON O ❑DEStRLICTION; INIFNbEO USE TYPE OF WELL CONSTRUCTION SPE REAHONS A ❑INDUSTRIAL ❑OPEN BOTTOM DUI.OF WELL EXCAVATION WA.OF CONDUCTOR CAMNM O ❑OOMEITKIPSTVATE GRAVEL PACK/SRTTYPE OF CAMMIBTETIPVC LRA.of WELL CACINO p I ❑PURUCMUMCIPAL ❑b1IVER DEPT"OF GROUT MEAL SPECIFICATION I, I ❑SIIomsowAa ❑OTHER OROUT MEAL INSTALLED eYryry GROUT IAAND NAME Q pk►.kj E ❑MpMtoWNa � GROUT SEAL IVMpEo!(3Yr I.J Ha COIICREIE PEOE9TAL BY DRRLEIk❑Y- ❑N. s" APPROX.OATH foto 70; , -ft W LOCKING CHESTER BORISTOVE PPE " �r S PROPO"m CORSTRUCTIONIONLLUM METHOD:MUD AOTARY AIR ROTARY AUGER CABLE OTHER 1 WwaYCtWWY THAT 1 HAVE PREPARED THIS APPLICAMM AND THAT THE WOW WILL SE GONE N ACCORDANCE WITH MAN JOAMN COUNTY ORDINANCES,STATE IAWI,AND RULES AND RFOIXATPON*OF THE SAN JOAOUSI COUNTY.HOME OWNER OR LICENSED AOENT'S SIONATURE CERTIFIES THE POLLGUNSM:'1 CERTIFY THAT RI THE ptFWORMANCE OF THF WORK FDR WHICH .I TMS PE MrF 19 ISSUED,I SHALL Not ETAPLOY PEMONRn SUS.IECTTO WOAOAAN'S COMPENSATION LAW"OF CALIPDRW&.CONTRACTOR'/MFMIIG OR oV"OM7ACTIHQ SIGNATURE CEMIFtES THE FOLLOIMNIO; •1 CERTRY THAT 1N THE R'EPIOIEVIANCE OF THE WORK FOR WHICH INTO PEgLOt IS gIV[O,1 SHALL,EMPLOY PERSONS SVSJECT TO WOgIOAAN'S CnilPphAT10N LAWS OF CALIFORNIA.' THE APPLICANT.MOST CALL 24"OU"AM AOVVA"CE FOR ALL PHIGMED INfPSC110NS AT ILMI I#-SII7,COMPLETE OMWIHfi AT LOWER AREA PROVIDEO, F 04p w A jF?EyJ /AIAIU I T11I. rfIS�A Trrrlc�A� O.e.O�/3�91 /Y✓/! S' PLOT FLAN IprM 1.0.0.1 Bp.b •h STT '" I.NAMES OF SFIIEET"OR ROADS NEAREST TO ON SOUNDING THE PROPENTY. 4, LOCATION OF/LOUSE SEWAGE DIaPOIAL SYREM OR pnorodEo S.OUTLINE OF THE PROPERTY,GIVINQ ONIEN"tONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DMMIAL 9Y9TEM8. I; X.DIMENSIONED OUFLMFM AND LOCATION OF ALL EXIeTRM AND PROPOSED M,LOCATION OF WELL"WITHIN MOMS OF ONE HUMORED tIFTY rT. aT UCTIRER,MCLURRNO COVEFED MEAS SUCH AS PATIOS,bIEVEWAYS,AND WALKS, ON THE PmPERTY OA ADJONNO FROPERTY. I . I � GEPAMMENT USE ONLY �//��,r1 fl T ' - APPtl.Nhn APPIpI.d BY. 0Th -L VV' I 1 Arr7�,. y `` 6reul Lrfe.IIPR nF P. Ir-p den eT nw Gwen,.IHn Mn...+len BT ON. 1 ACCOVN71N0 ONITI AIOF FACT fE CODES FEE INFO AMOUNT REASTTED CHECIUICASH RECTY[O MY BATE P6O,aT19FAVICE REOVEST NUMMM INVOKE 89 r G1' s65 4