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APPLICATION FOR WELL/PUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVIC ~' a40001 ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Tripnevis) APLICAT W N IS HERE BY MADE TO T/IE BAN JOAQUIN COUNTY FOn A PEM411 TO CONermICT AWOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TPILLEF,'C'HAPTER 8-1119.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE@,ENVIRONMENTAL HEALTH DMSION. JOS AODREBS/On ArNS o2 Q��1 1 h) W;lso n f�N)(A V CITYh /t��'}K KI(Y^ PARCEL Bt2E/APl7I OWRIER'B NAME �.., SHAno 1h 11 Q 1f 0I/ AODRESR A lJ )� Y Sh y7 RIONE LO -IV OG( coNTnAcron layAnl[ED GRO 4f/IV;F11nffi ±A1 Jn( AnORIee It uco ZZ PHONE(N 954-0 LK ^ ,c �i5t—e �Q� 85 SSg avRcor/tluc7onMi1c.11e)I OAI�'lF?G. �AV�11MPA•�A� ADonEeR-�O+ n}[ 2L7L 11C• 4/ ryIONE• C QAILP'I.O ICS-A �E $7yl TYPE OF WELL/PUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONn ORINO WEU/ ❑OTHFn ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL/ ,/ HYPE OF PUMP) ❑New❑F-1, H.P. DEPTH PUMP art FT. FIRST WATEn LEVEL__ 0 ❑OUT-Of SERVICE WELL ❑OEOPIYRICAI.WELL I I$ ROIL BORING a•3�R-L/ R IJ OF-7 RUCTION:INTENDED USE TYPE OF W CO STRVC TION SPECIFICATIONS Q �f A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WEIR EXCAVATION ZJ- .L nch! DIA.OF CONDUCTOR CARING N109 p ❑DOMERTICA`NVATE ❑ORAVFL PACKMIEE TYPE OF CASINOISTEEtRNC 1,44 GIA.OF WELL CASINO NO ❑EVRUC/MUMCIPAL ❑DRIVEN DEPI//OF GROUT SEAL RPECIFICATION ♦v R ❑mR10AVOWAG ❑OTHER GROUT SEAL INSTALLEDBY -TAft)lt my oD GROUT BRAND NAME I E 11 MONITORING /•� f'C C C GROUT SEAL PUMPED:Fly. [IN. CONCRETE PEOE RTAL SY DM ER:®Yw CIN. 5 APPROX.Of.."" 4A D^ r c� 8,J or LOCKING,CHESTER RO%IR7o Ve PIPE /U �_ S PIOPOSM CONSTRUCTIONMAILUNO MFIHOD: MUD ROTARY AIR VOTARY AUGER ' CABLE OTHER I HERESY CERTIFY THAT I HAVE PREPARED INIS APPVCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OPOINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE PAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES 711F FOLLOW'INO:'1 CERTIFY THAT IN THE PEREOPMANCE OF THE WORK FOR WIBCH TIB@ PERMIT IS IRRUED,1 SHALL NOT EMPLOY PERSONS SUBJECT 70 WORKMAN'S COMPENeAHON LAWS Or CALIFORNIA.-CONTRACTOR'@ I/IRINO OR SU"oNTRACTINO SIONATVRE CERTIFRS 711F FOLLOWING: 'I CERTIFY THAT IN THE PERTONAANCE OF THE WORK FOR WHICH THIS PERMIT IR ISSUED,1 WALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAI.IFOMM�AA..' THE APPLICANT MUST CALL 74 HOURS ,IN(�ADVANCE FOR ALL REOUMEO OISFECTItO�N6 AT 170514W-11].COMPLETE OMWINO AT LOWER AREA PROVIDED. Q BIe,w1 x_ / ` a . CL-0 19 TAR.5'��.r (' ��1 Q�S� D.e. T� y^/ PLOT PLAN 131.w Ie 8.0.1 P.O. 'Ie 1.NAMES OF STnEETB OR ROAD@ REARERT TO OR BOUNCING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On P10PO6E0 2.OUTLINE of THE 17OPfRTY.WINO DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL BYRTEMS. O.DIMFNRONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED PIPTY h. RE STRUCTU@,INCLUDING COVERED AREAS SUCH AS PATIO@,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY, P/1ii ....: .. .. .. :. .. 1 T :... ... . . .... .. .............:.......... ............ 4.....:.....:......:.. :... ... :..y::.. ... ........:.............. ..... .......... ...... ............. : DEPARTMENT USE ONLY AImOe.11en AennpR.M Br O.R. // / A- 00. uD.Ie RLnP Imne.Ren er mI. O•.I,R.e1bn Rn.n.nlMn Br D.R. Cnmmerpr ACCOUNiMO ONLY: AID/ FACS PE CODES FEE INTO AMOUNT REMITTED C FICASII RECEIVED BY OAi PU MIT/SIJAVICE REQUEST NUM@9I INVOICE Pub.Health Serv.-Envlro.173(1/97) _ ��