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*APPLICATION FOR WELL/PUMP PERM SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209) 488-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DI P Momplom In Tr*kfetEl APPUCATION IS HERE BY MADE TO THE SAN JOAOUM COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.7 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESSMA APN,/L. Iy,�z In.,,Gc.� �. cm( 5'?DCK�° Int .} PARca wvAFNff 13'J- 3 OWNER'S NAME S 1tc L-6cl— �Q��TII/�^� S /.j L (SOLI, Sl U NAf '7S ZO Z p T V 14 (/ 1, I[ff A0 y r�SlO L/ n CONTRACTOR_f Rf.G j-4; I'd Al ADDRESS 1100 S- Sd-1(„5t UC) M43$ Y PHONE.��-'f S/S oTJSUCTA nT'T LA G-I�/J v K 7-0 K/ � ADDRESS KOLL C-r Q- Pk /�fiSR/"brwNE 1 qzs TYPE OF WELLR'UMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J ❑Naw❑FaP N.P. DEPTH PUMP BET_". FIRST WATER LEVEL 111.� - 11�J� _ 1� �L O HYPE OF PUMPI ❑ O�UTT-0`FSERVIC(E�WELL PH - ❑ GEOYSICAL M�/1E'M I � L, 'SOIL WRING /j til j IRJ13 ❑DESTRUCTION! IIJCOsr-4 WI Ilp/YLY^�-l.TrvFo� - INTENDED USE TYPE OF WELL(� CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA-OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p ❑ DOMESTICNRIVATE ❑GRAVEL PACK/BRE TYPE Of CASmdSTEELIPVC DIA.OF WELL CASINO p ❑ PUBUCIMUNICMAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ MIGATMNIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED:❑Vr ON. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑Na S APPROX.DEPTH LOCKING CHESTER BOX/STOVE FIFE $ PROPOSED CONSTRUGTON/DRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER- -:HE^ SV CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SMNATURE CUITIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEPPORMANCE OF THE WORK FOR WHICH THIS KRUM 18 ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALMORJRA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOPEK FOR WHICH THIS PERMIT IS ISSUED.1 MALL EMPLOY PERSONS SUS.IECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.' THE APPIIC NT RUST CALL 24 MOW IN ADVANCE TOR ALL REQUIRED IMSRCTIOMS ATyy1�� 1 4"S =. COMPLETE DRAWING AT LOWER AREA PROVIDED. Iil.nad z M. rid-TI _ l-�%R'Lael A-� D.<. Z�/ 67— x PLOT RAN IDraw I.f.Wl S W •'I. 1. NAMES OF BTREFTS OR ROADS NEAREST TO OR llTIDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR MMSED 2. OUTLINE OF THE PROPERTY,GING DIMENSIONS AND NORTH DIRECTION. "PANBION OF SEWAGE DIB SAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED E. LOCATION OF WELLS WITHIN MOMS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. l I . l� - 1 l/11 DO INTENT USE ONLY Applb.tbn Aaeapled BY ` ♦. DN. deal Imprlbn 0Y ONe PMap InaprUan By Orvnalbn IrMveNbn BY ON. ACCOUNTING CNLY; AIDO FAC) - R COOE1 FEE-INFO AMOUNT REMITTED CHK%f SASH RECEIVED BY DATE PERMIT/SERVICE AIMUEST MU.ISER1 INVOICE 2 0 ( moo o Clqq3 C) Pub.HeeRh Sew.-F-,Mm.173(V97)