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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 RON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE133UED rm"IGI•In TilpketS1 APPLICATION IS HERE BY MADE TO THE SM JOAOUIN COUNTY FOR A PEMAIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE CHAPTER 9-1113 3 A T RANO • tAN JOAOVM CO T'PVBLK HEALTH SEIIVICES,kT/LTONMfNTK HEALTH DIVISION, 7 p l JOB ADOREemn APNS OC- �. W✓ L ilIt CT' I PARCEL SUEJAPNIIci� ° .zpov oWRNFn•s NAME ('l G y`SQv� Aool+E•• /E L,. 1 PHONE CONTRACTOR `S I K AodEn�� {�/LC.^rAdl, LK:/�l'6t Z FFIONE�� SUB CONTRACTOR ADDRESS UCI PHONE/ TYPE OF WELL/PINAF:>Ct1EW WELL ❑REPLACEMENT WELL ❑mowo NG WELL/ ❑OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCO WECT LIE►AMI ❑VAPOR EXTRACTION WELL/ J ❑Nw.Q R-•Y N.P. DEPTH RUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMIPI — ❑OUT-0F-SERVICE WELL ❑OEORIY•ICAL WELL/ ❑ SORE 10IBNO / ❑DESTRUCTION: INTSNDED WET CONSTRUCTION SPECIFICATION• A ❑INDURNAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASNO O T �'.pOMEBTICRRVATE �'RAVEL FACK/tRE TYPE OF CABINO/IT EEINVC T— DIA.OF WELL CASING � O -- 11PUSUCM11fACPAL ❑ORVEN DEPTH OF GROUT SEAL 10d9 SPECIFICATION R IBBOATIOHIA: ❑OTHER :ROUT SEAL INSTALLED BY OROUT BRAND NAME! f ❑LIOWTORNO ^7^ n :IIDVT SEAL"Amo!"50- on. CONCRETE PEDESTAL B OPALER:❑Yw 4Z!• S APPROX.DEPTH_( �/ F LOCK"CHESTER BOXISTOVE PR s PROPOSED CONRRVCTIOIIDFBUING MRHOD:MUO ROTARY ALR ROTARY AUGER CABLE OTHER 1 HFESY CFNTPY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE tl1N JOAOUIN COUNTY.HOLE OWNER OR LCPMD AGENT'S SIGNATURE CERTIFIES THE FOLLOWNO:'1 CERTIFY THAT N THE IM I FORAANCE OF THE WORK FOR WHICH THIS PEIKNT IS ISSUED,I WALL NOT DAPEOY PERKING GUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.'CONTRACTOR'S HISS:ON SUSCONTIIACTNO SIGNATURE CERTMEB THE FOLLOWING: 'I CERTIFY THAT N THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT N ISSUED.1 SHALL EMPLOY PERSONS IRAUIECT TO WONSMA N'S COMFv1•ATKIN LAWS OF CALIFORNIA. Of APPLICC,L{A/N�T MINT C HOURS N ADVANCE P011 ALL REQUIRED p1FICTTIOO AT 12001400-3,4".COLPLITE DRAWING AT LOWER AREA PEOVVM. �y ON."X V �`Ci E I L�� TM• 1 J FI L L l�� On•S�41 PLOT PUN V—I.S••IN Sub 'b 1.NAMES OF SOUNDING!ON ROADS NEAREST TO OR SOUNDTHE PROPERTY. A.LOCATION OF H01ISE SEWAOE DISPOSAL SYSTEM OR PROPOSED IN S.OUTLE OF THE PROPERTY,ONIA DMORMONG AND NORTH DIRECTION. M N. FXPANON OF SEWAGE DISPOSAL SYSTEMS. O.DRAEO NSNED UONISND OUTLINES ANO LOCATION OF ALL RAPROPOSED E.LOCATION OF WELLS WTINN RAMS OF ONE HIIAREO FIFTY FT. GTRUCTUREt,SCUDS:COVERED AREAL SUCH M PATIOS,ORV11WAYG,AND WALKS. ON THE DOPER"OR ADJOINM PROPERTY. ......'....d.....i... ..i...i i... — I I ) y :... ... 1 1, PAYMENT -- . 1 I RECEIVED fd dOAQUIN SCANTY H .L7 DEPARTMENT USG ONLY DMSION AENI.Hbn Au�I•d BY ��1(7+�_� on. J �/ �o A... �/N MM Y,HE•aUsn BY �• I�>•^F In•psn.n By Dn• 0w.1n:•Ibn Mw••II•n D•1• K. .... ACCOUNTNO—1: — FAC/ PE CODES FEE INFO AMOUNT REASTTED CHIC MAAH RECDVEO BY OATS PZMFATISDIVICE"aUFST NI mem INVOICE +3 I I� 8o�1 I,p, S 9g 0 55 1a Pub Health Sam.-ErnAro.173(1/97)