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TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ Mowcm,mG WELLf ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL f ✓ ❑Nav❑RaPNR H.P. OEPrH PUMP SET_FT. FIRST WATER LEVEL O ITYPE OF P/MR ❑ OVT4FSERVICE WELL ❑ GEOPHYSICAL WELL f ❑ SOR SOMNO S 106i(ND81 USE ryEmm CONSTRUCTION SPECEICA 10 ❑INousTMAL 13 OPEN BOTTOM DIA. OF WELL EXCAVATION t1 DIA. OF CONOUCTORCABMO ❑ DomesTocormATE ❑ GRAVEL PACK/BOE TYPE OF CAMR)fSTEEL/PVC DIA. OF WELL CASING L L p ❑ PUBLCIMUNICIPAL ❑ ORVEN DEPTH OF GROUT BEAL SPECIFICATION R F� ❑ IMMGATOWAG ❑ OTHER OROUT BEAL INSTALLED BY GROUT BRAND NAME E LJ MONITORMO GROUT BEM PUMPED: ❑ V® [In. comFtm PEDESTAL SY omum ❑ Y« ❑ NA S APPROX. X. DEPTH LOCKMG CHEBTER BOXISTOVE P'I@ PROrOSxzlMMLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER (+ HEREBY CINGV Y THAT I It AVE PREPARED THIS APPLICATION AND THAT THE ITL WTI. BE DONE ACCORDANCE WITH BAN MAGIAN COUNTY ORDINANCES. STATE LAWS. AND RULES NO /EOULAYMNS OF THE SAN JOAOUM COUNTY, NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: *1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR N TINS PERMIT Is MOM, 6 MALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIONUWB OF CALEORRA.' COMMCTOR'B HIRING OR SUBCONTRACTING SIGNATURE CERTI 8 THE FOLLOWING: ' 1 C RTEY THAT 1 TtE PE RMANCE OF THE WOML FOR WHICH THIS PERMIT m ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT TO WOIMHAN'S COMPENSATION UWB F CALIFORNIA.'ALIFOA.' THE ANT MV CALL 2 LAIN IN ADVANCE FOR ALL MOUNTEDKC1110 A/T 112WI40044.22. COMPLETE DRAWING AT LOWER AREA PIO y/LE9G BtOmd %'� D TOa -le Q`j 0& S/ DNs E/1 [ PLOT RAN Inv b Bede) 8W, to 1. NAMES OF STREFTB OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ^ 2. OWU E OF THE IMO PROPERTY. GIVING DENI NG AND NOWN DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXIBTINO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDIED FIFTY FT. STRUCTIAEB, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYB, ANO WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 77 uw� . _ a 3�1 .A, . /kw�330 ,M4r6a� SDI tl.. Mw CD3 (� PAYMENT RECEIVED plwLD2 JUL 8j Sh1TJ1 21Nq)UNTY "► t . ENVIRONMENTALH eERVIOES,^.. R wY �� 6� DEPARTMENT USE ONLY Alree.•tlsnAe.wt.eer�3/\�`. d+� wl.�(J�.__--__.1�_T_�___�'LA�.. r�-L� Mout hlrooeNen By D.t. rspy/ bn er pU.} t)wntetAn Intim \— —.- - - ./c'1 l,(le 1-6-0. - I All *41-- - - ACCOURTMO ONLY: I AOR FAC/ PE coon FE[ INFO AMOUNT REMITTED HECK/ ASN RECDvro By DAT[ -- 70Pe COI.�t Dt f7 6XP W17// JFK /iGkl O' ' Wf+Js PEMOTHEAVICB REQUEST MUNSERI f AFsBi APPLICATIO OR WELLJPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 0 Mi -REFUNDABLE N•REFUNDASEE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2G _ 39 It' 6 wom111Bts M TrIpREBts) APPLICATION m HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOFK DESCF BED. THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN Co JOAGUM COUNTY DEVELOPMENT TITLE, CHAPTER 8-1116.. AND THE OF BAN JOAOUIN CO NTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH OPAWTH. /� 1 JOB ADDIE88PDfl APNf_ t CITY _ PARCEL BIZFJAPNI LG1-1(46 —,4/ OWNER'S NAME A �Td � PHOF$Iln _ A BS I�y�.,C/` ^I CONfNCTOR wd y�f ADD ESS Ln J CF M/, UC# x'77 �' RHONE f O .�.(• �A�rp SUS CONTRACTOR 1 R V FV ` n— +� AOORERS/T�� "(�A!{i/i�I W' J!F^� l ?UCf iizd RINE S�I Gam.. n�- �rx Sar TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ Mowcm,mG WELLf ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL f ✓ ❑Nav❑RaPNR H.P. OEPrH PUMP SET_FT. FIRST WATER LEVEL O ITYPE OF P/MR ❑ OVT4FSERVICE WELL ❑ GEOPHYSICAL WELL f ❑ SOR SOMNO S 106i(ND81 USE ryEmm CONSTRUCTION SPECEICA 10 ❑INousTMAL 13 OPEN BOTTOM DIA. OF WELL EXCAVATION t1 DIA. OF CONOUCTORCABMO ❑ DomesTocormATE ❑ GRAVEL PACK/BOE TYPE OF CAMR)fSTEEL/PVC DIA. OF WELL CASING L L p ❑ PUBLCIMUNICIPAL ❑ ORVEN DEPTH OF GROUT BEAL SPECIFICATION R F� ❑ IMMGATOWAG ❑ OTHER OROUT BEAL INSTALLED BY GROUT BRAND NAME E LJ MONITORMO GROUT BEM PUMPED: ❑ V® [In. comFtm PEDESTAL SY omum ❑ Y« ❑ NA S APPROX. X. DEPTH LOCKMG CHEBTER BOXISTOVE P'I@ PROrOSxzlMMLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER (+ HEREBY CINGV Y THAT I It AVE PREPARED THIS APPLICATION AND THAT THE ITL WTI. BE DONE ACCORDANCE WITH BAN MAGIAN COUNTY ORDINANCES. STATE LAWS. AND RULES NO /EOULAYMNS OF THE SAN JOAOUM COUNTY, NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: *1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR N TINS PERMIT Is MOM, 6 MALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIONUWB OF CALEORRA.' COMMCTOR'B HIRING OR SUBCONTRACTING SIGNATURE CERTI 8 THE FOLLOWING: ' 1 C RTEY THAT 1 TtE PE RMANCE OF THE WOML FOR WHICH THIS PERMIT m ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT TO WOIMHAN'S COMPENSATION UWB F CALIFORNIA.'ALIFOA.' THE ANT MV CALL 2 LAIN IN ADVANCE FOR ALL MOUNTEDKC1110 A/T 112WI40044.22. COMPLETE DRAWING AT LOWER AREA PIO y/LE9G BtOmd %'� D TOa -le Q`j 0& S/ DNs E/1 [ PLOT RAN Inv b Bede) 8W, to 1. NAMES OF STREFTB OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ^ 2. OWU E OF THE IMO PROPERTY. GIVING DENI NG AND NOWN DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXIBTINO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDIED FIFTY FT. STRUCTIAEB, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYB, ANO WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 77 uw� . _ a 3�1 .A, . /kw�330 ,M4r6a� SDI tl.. Mw CD3 (� PAYMENT RECEIVED plwLD2 JUL 8j Sh1TJ1 21Nq)UNTY "► t . ENVIRONMENTALH eERVIOES,^.. R wY �� 6� DEPARTMENT USE ONLY Alree.•tlsnAe.wt.eer�3/\�`. d+� wl.�(J�.__--__.1�_T_�___�'LA�.. r�-L� Mout hlrooeNen By D.t. rspy/ bn er pU.} t)wntetAn Intim \— —.- - - ./c'1 l,(le 1-6-0. - I All *41-- - - ACCOURTMO ONLY: I AOR FAC/ PE coon FE[ INFO AMOUNT REMITTED HECK/ ASN RECDvro By DAT[ -- 70Pe COI.�t Dt f7 6XP W17// JFK /iGkl O' ' Wf+Js PEMOTHEAVICB REQUEST MUNSERI f AFsBi Pub HeaM Sero. - ERrvIo. 173 (1/97)