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-APPLICATION FOR WELL/PUMP PERLV -, I SAL )AQUIN COUNTY PUBLIC HEALTH S9' ''CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 I (209) 48$-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (COmphte In TTIpl mr) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND708 INSTALL THE WOF%DESCRIBED.TRIS APPLICATION to MADE IN COMpUANCE WTTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 11 S.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, i JOB ADORESWOR APNO 503 F—R 5 T TENTH S i fti`E TCITU G.. T R R 4 13 5-A 9 � PARCEL SIZEIAPHf9. _ q L �� 617 OWNER's NAME CVVNrY nnQ tF SAN ;�'CA�i11 VIN ADORESs22Z ptbLr V8•� 17 FlCo�'gg�)PHONE f 20914 G 6'$97 I I CONTRACTOR V+W W R 1 L L 1 N ADDREBB P Q Q .I LIC/'�T�OJ V PHONE 1 7y1°3-fq, SUe CONTRACTOR ADDRESS R_lc `5 qrt CA 3415TT LICE RHONE S Isis - TYPE OF WELLf umm Id"EW WELL ❑ REPLACEMENT WELL MONrTORMHO WELLf •7 L J '❑ dTHEfl . ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLf J (TYPE OF PUMpI ❑New❑RePelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O . .❑ OUT-OF-SERVICE WELL ❑ OEOPHYSrCAL WELL f ❑ BOIL BomNG a ❑DESTRUCTION• INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM 1 DIA.OF WELL EXCAVATION- p"I^6 _ DIA.OF CONDUCTOR CASINO N D ❑ DOMESTIC/PRIVATE GRAVEL PACK.10ME. 3 SA etcL TYPE OF CASMHGtST£Et1PVC V L GIA.OF WELL CASINO Z_ `^ C D 11PUBLIC/MUNICIPAL ❑DmVEN DEPTH OF aflovr SEAL__4__ [___ _�.t 1 SPECIFICATION 5C 4 0 -0[01 y C IGv l R 13 RRIGATIONtAO ❑OTHER GROUT SEAL INSTALLED BY 11'L'KA I P_ GROUT BRAND NAME_ 414 t Ge*4 a yjj E L'1 MONITOAINOy A� GROUT BE/.L FVMpEq;CJ Yae Ln No CONCRETE PEDESTAL SY DmU.EFE❑Y— W Ne S APPROX.DEPTH •y V fee {y� LOCKING CHESTER BOXISTOVE PIPE ., S PROPOSED CONSTRUCTIONDWLIJNG M1 THOOi MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEdEBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AHO RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.'NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOVNNO;-1 CERTIFY THAT W THE PERFORMANCE OF THE Wow FOR WHICH' THIS PERMIT 18 ISSUED.I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAII'S COMPENIIATION LAW$OF CAUFORNUI.- CONTRACTOR'S HIRING OR 8118-CONTACTING=NATURE CERrIFIES THE FOLLOWING: "I CERTIFY THAT IN THE RMANCE OF THE WORK FOR WHICH THIS PERMrT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO W6111MAN'S COMPMOATION LAWS OF CALIFORNIA.' PPLICANT M ST CALL11Re IN ADVANCE FOR ALL flEOI>1RrD IMePOCTIO S AT T2M14d-}/2I. COMPETE DRAWINO AT LOWER AREA PROVIDED. Planed x TIRe D+te df PLOT PLAN Mr—to el Salve 'I. 1. HAMER OF STREETS OR ROADS NEAREBT TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED II 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIePOSAL SYSTEMS. 3. DIMENSIONED OUTLIES AND LOCATION OF ALL EXWTBHO AND PROPOSED 6. LOCATION OF WELLS WITHIN MONS OF ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WAUCS. ON THE PROPERTY OR ADJOINING PROPERTY. ' ............ .................. COPS jji ........... ........................... ................. DEPARTMENT USE ONLY _ I APPIIae1len Aaaeeted BY G(// o..—Ac �•� Mr O—A IrxP 11l BT I./\��Mn r G1/\ Dols V '�^`� ! 31anv lnsoeaHon BY Dole � J De.+reeebn tn.veatbn Br bole i Cern�Me• . ACCOUNTING ONLY, Atbl FACS - PE CODES FEE INFO AMOUNT REMITTED CHECK1tCASH RECEIVED By DATE PERMITISERVICE REGUOT NumsmR INVOICE 320 1031 2n, L-L-1�r o Sto Pub.Health Serv.-Enviro.173(1197