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F-•i �� J r APPLICATION FOR WELLIPUMP PERMIT .A. .w ,j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC ENVIRONMENTAL HEALTH DIVISION A P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 96201-388 a (209) 4883420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED eJ l� (CoWlsom In Triplicate) APPLICATION IS HEIS BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTAL THE WORK DESCRIBED.THIS A ATION IS MADE IN COMPIIANCE WITH SAN 1 "AMIN COUNTY DEVELO/P�M�EENTT TRUUE,,'rC�HAPTER -1116.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB AOORE88N1V'W`r\MIIII; / �+ 1�V �!L � CRY 1 1�. `-i v 1 111 pggCEL SITE/APNI l' (/ (� ` `I OWNER'S NAME//WZ!1"' ' lir L�-FI�� ADDRESS (� / - 1 j� FMNEf JI'O �~ /'1 r CONTACTOR_ wJ\LL�I� YV� �!•)l{�'YLM r✓I q-V I ADDRESS 1� c-,y ,- (N Py- L 6sly I(I RHONE tYA9��6,-U-- -07fA SUB CONTACTOR lh(;i)k Au N ADDRESB� i 0 9 �RIC# `x�3 1 RHONE si b 6,- -66 13 TYPE OF WE wmp: �,❑ NEWWELL ❑ REPLACEMENTWELL 11 MONITORING WELL# 13 OTHER ❑ INSTALATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ 110 Na 13 Repair H.P. DEPTH RUMP SET_FT. FIRST WATER LEVEL `P RYPE OF RUMR I ❑ OUTCF SERVICE WELL ❑ GEORHYBICA.WELL# I'KI BOIL BORING B ❑DESTRUCTION: INTENDED WETYPE OF WELL CONSTRUCTION SPECIFICATIONS A 1 1- ❑ INMIaTPoQ iI ❑OPENBOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ OOMESTICRRIVATE ❑GRAVEL PACKfBRE TYPE OF CASINGWEEIIPJC DIA.OF WELL CASING D L ❑ FVBMCRAUNICIPA.'3 ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICAMN - R` ❑ IRRIGATION— ❑OTHER GROUT SEA.INETALUKD,..B/Y GROUT BRAND NAME E O ❑ MONITORING II GROUT SEAL NMPED:0(1 Vs ❑Ne CONCNETE R:OESTAL BY DWLIFA❑Vs ❑No S �+ APPROX.UFITN O LOCKING CHESTER BOX/ OVE RPE PROPOSED CONSTRUCTIONRMtlWNO METHOD: MUD ROTARY AR ROTARY AUGER CABLE OTHER PuS 1 HEREBY CERTIFY TAT 1 HAVE PREPARED THIS APPMATION AND TAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAMN COUNTY ORDINANCES,STATEUW6.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR MERGED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED;1 SRHAL NOT EMMOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAMFORNM.- CONTRACTOR'S HIMNO OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWII O: °I CERTIFY THAT IN TH PERFORMANCE OF THE WORK FOR WHICH THIS p�PERMIT IB ISSUED.I SHALL EMPLOY FERBONS SUBJECT TO WORKMAN'S C PENSA N TAWS OF SbroWRNIA.' TIE ARID ANTMWTC ROH lNB RICE ORAILRETItIe 1 �1 n AT120H1 Y�8� n. COMPLET�WINGATIDWERDeAN�A PHK) . i. t PLOD RAN RIDE le 8pYs1 Swb�_'m 1. NAMES OF SIRE PR6m ROADS NEAREST TO N BOUNIXN.'THE PROP'RY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PRDPOSED I11 3. MURINE OF THE PROPERTY,GANG DIMENSIONS AND EXISTING H DIREL f1..N. E%PAN ON OF BEWMWTHIDISPOSAL RADIUS BS OF ON S. 3. DIMENSIONED OCTANES AND LOCATION OF AL EX18RN0,D DRIVEWAYS, S. VOCATION PR OF WELLS WITHIN RADIUS FE ONE HUNDRED FIFTY ' 6TRUCTUIREB,INCLUGHNG COVERED AREAS SUCH A6 PATIOf�,DRIVEWAYS,AND WAXS. l--E ON THE PROPERTY OR/ADJO/ININ'G PROPERTY. 1 • 1 \ + �(201 /�JO✓�/� � . 2 31 Sta>z Fetal 5tae Fad ... ... II u sldev✓alk ` II _. P e O h N q ......... rrw-I - ' i LF�GEj li ® FarReF" d3T b '�...^�' GTnundwatu NrvH#Drmy Well . rU M AurQmotRrc3 • p ( nnq L=o I r 6C1E.loth 6&rcty _ (wbjectto4ekJmFiTMnS) DEPARTMENT WE ONLY A,I*b bn Aeee BY Grow Iropenbn By Dm. Pomp Impettlon By. Dns _ DYtAmbn iropenbn By Wta Commenb: I ACCOUNTING ONLY:! ADI FAC# .I PE CODES FEE INFO AMOUNT REMITTED C ASH RECEIVED BY DATE, PERMIT/SERVICE REQUEST NUMBER INVOICE G ?3 P?41 li r li k I