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OPPLICATION FOR WELL/PUMP PERS SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEA,FROM DATE ISSUED D rJ_ la( )31114, APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPM1 ENT TITLE.CHAPTER 9-111 B.3 AND THE STANDARDS OF SAN AOUIN COUNTYPUBLIC HEEAALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESSIOR//AM#n} l 3 ( ^�(�1�O - ITS S�/S1 �' � CITY J� 5tp CK-Tb yLL V PARCEL 8IZE/APNI OWTIER'SNAME//''U aJF' AL� OYA10E I0 L-J-aA,L a2zd — ADDRESS r.QO. Q� O1I, I r IW�Y1�11�/L�L_L'-C CA453 P/ro1NEr CONTRACTOR LZ Re C-IS bRl L.L..IM& ADDRESS l5JO Owe St, II IFI R'TI uC 4, SI Z{O ( PI�ioNEr3'3 -S 80D DnSuLri+An weeeNSRA,eTort— LA ADDRESS L9Zc, OL.L- Cr ICASAXX gLSr ZL-ZLOD TYPE Of WELVPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROS"ONNECT REPAIR ❑ VAPOR EXTRACTION WELL r J ❑New❑Ps* H.P. DEPTH PUMP SET_FT, FIRST WATER LEVEL G RYPE OF PUMP) �}Ne ❑y OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I P SOIILL BORING NL�! ,�I"k B ❑DESTAUCTION: �nV"^"gyp Sb IA �Q(j,1 � ryLCit l} LI - /LQiHML'\_La. IUYk/ INTENDEO USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTICIRBVATE ❑GRAVEL PACKMME TYPE OF CASIMMTEEL PVC DIA.OF WELL CASINO G ❑ RIBLICIMUNKMA ❑OMWN DEPTH OF GROUT BEAL SPECIFICATION R ❑ INRGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONTTONNG GROUT SEAL PUMPED: ❑Yr ❑Ne CONCRETE PEDESTAL SY DRLLER:❑Yr [IN. S APPROX.DEPTH LOCKING CHESTER BOXMOVE PPE S PROPOSED CONSTRUCTION/ UJNG METHOD: MUD ROTARY AIR ROTARY I AUGER CABLE OTHER I HE^ BY CERTIFY THAT I ILAW PREPARED THIS APPLICATION AND THAT THE WOLK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES ANO REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEWORMANCE OF THE MW FOR WHICH THIS PERMIT IB ISSUED,I SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTMCTOR'e HIRING OR BUB-CONTRACTING SIGNATURE CEMIFIE9 THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOHL FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN&ANON LAWS OF CALIFORNIA.- THE APPLICANT U PT CAM 24 HHOUR&IN ADVANCE FOR ALL REOURSD INSPECTIIOLNS AT(100014004yA.22...COMLLETE DRANANO AT LOWER AREA RIO DEO. vqE X C/"/4 wF/�� TIP. � - T-/L-Q)l-.�C r " W^n^lf-� 0.1. Y a Da—. PLAN IDr.w to ee.lsl Se•le -to 1. NAMES OF STREETS OR WADS NEAREST TO OR BOUlJOING THE P(OFFRTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR POIOSEO t. OUTLINE OF THE PROPERTY,O(VING DIMENSIONS AN NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. O. DIMENSIONED OUTUNF.S AND LOCATION OF ALL EXISTINO AND PROPOSED - S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. G'-1�'- -�- " Qtid-= II `Y�to Sr???llrtrlctiG I ' 1 � � I soba .. ¢ate QaY-a a . jD 50, cPTp Q-� (DP-)a l31 )L{ -'e ])P- t ) DEPARTM TUBE ONLY APPIMetl A. td BY /"T ONe O` Mee Oreal Fweenllen BY Date PMnp Imoselien By 'DiR�-r Oe•mRtbn Imoa:bn By Oete cemmem•: 1' ACCOUNTING ONLY: NDE FAG PE COD" FEE INFO AMOUNT REWTTED CHEC"XAAH RECEIVED BY DATE PEPMITISERVICE REQUEST RUMORS INVOICE 0 00 0q? Pub.Health SEN.-Enviro.173(1/97)