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*APPLICATION FOR WELLPUMP PERM SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WESER AVENUE,STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE 133UED �p_a p (CampwtE In Tr(pikatal APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR MSTALL THE WOW DMMUD.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11111 S.3 AND/THE BTANDARD9 OF BAN IOACUIN CODUN Y PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DM.M, JO$AOOREsstom AP'N,.o � 5 �J�(n'C'Q m J/ — C -rD CK (1- Nay PPAARCEL SIMAM0137 - '3 OVMER'8 NAME ADDRESS 103 5. �✓TY'wK^�W `J I"-T^-•'-`-�SPRro f coNTR MnCIKE&G D21c.�laG ADORE8895o l.leS'�. mRR'T'^IUGci-(a56`}o7pHOZNEa315 -5760 n to vL f'/-V Air S4J84 tOR— LAYSUN ADOMBS (-Ito DLL Ci-K. PI's",VCI LGrttA�°��5. ZL-ZLoo TYPE of WEUJPUMP ❑ NEW wELL ❑ R EMENT WELL ❑ MONITORNO WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SY9TEM REPAIR ❑ CHUSS-0ONNECT REPAIR ❑ VAPOR EXTRACTION WELL$- 11 N.cl ❑N.cl Fe W H.P. DEPTH RUMP BET_". RMT WATER LEVEL O (TYPE OF PUMP N �OC� p ❑y OVT-0FSERVICE WELL 1. ❑I 1O1EORIYBICAL WELL I BOI/L�BOPoNO g DESTRUCTION, Vim" -T�—, ly O��0.J1 y.lI 7L 1Lr`Cat' JiL GJ �/LQM✓Y1�4. AT INTENDED USE TYPE OF WELL CONSTRUCTION SPECIRCATIONG A 1 ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING _ D ❑ DOMESTICNRVATE ❑GRAVEL PACKMQE TYPE OF CASINGAITEEVPVC WA.OF WELL CASING O ❑ RIBLI mutacwAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIRCATION g ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED:❑Y•. ❑Ne CONCRETE PEDESTAL BY DRLLEM❑Y. ❑Na S APPROX.DEPTH LOCXINO CHESTER BOXIBTOVE RPE 3 PROPOSED CONSTAUCTONlOPoWNO METHOD; MUD ROTARY AIR ROTARY AUGER CARIE OTHER I ME Ry CERTIFY THAT 1 HAW PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE M ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAW9,ANO ZE3 AND REGULATIONS OF THE SAN MAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,i SHALL NOT EMPLOY PERBON8 SUBJECT TO WORKMAN'S COMPENSATION LAM OF CALIFORNIA.- CONTRACTOR'S HIRING 09 SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOO WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUWECT TO WORKIMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUPT CALL24MUS IN ADVANCE FOR ALL REOURM ININSPECTIIO1NS AT 120}4. 4b/vJty4.2.�3.. COMPLETE DRAWING AT LOWER AREA PRO D�ELD. BIP.,•M X <-"�4 T18._ ..d'L T"/LvIJ•+-C I V'^n"'I f, D.T. L C% �OT PAN pAPw to Be•I.1 8e•I• 'R I. NAMES OF STMET8 OR ROADS NEAREST TO ON BOUTJDING THE RIOPERIY. 4. LOCATION OF HOUSE SEWAGE OIsPosM.SYSTEM OR P cMSM 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AN NORTH DIRECTION. EXPANSION OF SEWAGE D18POBAL MTEMB. 3. DIMENSIONED OUTLINER ANO LOCATION OF ALL EXIBTMO AM PROPOSED E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FR FT. STRUCTURES,INCLUOINO COVERED AREA$SUCH A8 PATICS,OR AYS,AND WALX3. ON THE PROPERTY OR ADJOINING PROPERTY. dl1 r� _ .. log �.�::: �•->�. ,�.as;...d- .(�-�,.a " . ��,�' .f�'1�G� c�11 L1 (/� I/p��'1ATM us ONLY Applla.Sen A. Nd By .'�L /!M1' 1 /Ci V/ ` ✓ \ L TM D.I. A �� a�/ \ A,.e G.m"P-9—Br D_ Puns InwePGen _ �� O.RL Oewnnlbn hnPeelbn BY D.b CammwMe: c 1 A ACCOUNTWO ONLY: AID# FAC$ Y PE CODED FEE INFO AMOUNT REMITTED CHEC"MASH ncC DATE PERMITRERVICE RECUEDT mumem INVOICE 4 04233 PL:h.Health Serv.-ErMro.173(1197)