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2-04-2000 11 .23AM FROM P. 2 APPLICATION FOR WELLIPUMP PERMfI SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX aft 304 EAST WEBER AVENUE,STOCKTON, CA 95201-W (2091 468.3420 ,NWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Gmpllto In TrlpRwtl) APPLICATION 18 NOW BY MADE 70 THE SAN JOAQUIN COUNTY FOR A PERMIT 70 CONSTRUCT ANO(DR INSTALL THE WOW DESCRIBED.TINS"TMATION It MADE IN COMPLIANCE WITH! JOA(IIIrN COUNTY DEVELOPMENTpTtTLE,CHAprEn 9-1 1 1 5.3 AND T STANDARDS OF SAN JOAGM COUNTY PURI.IC HEALTH SERVICES,ENVNOONMENTAL HEALTH DWTSIDN. JOB ADDAESSlOR APNIr D lC)cl CITY �((a.�� A PAIRCEL S12F/AVN91� OWNER'S NAME t Il �C. t TC L t'T�L 1 S 6A IQ g eSGtl A AnOREBs__- I/Q��?{70 S, �4rI4_� 1 f/ �^/PTIONE o9 1 CONTRACTOR -s?C -1 ao&h �� ADDFESS^3(l' W It.,intA Dr PI+oaF 4�` SUB CONTRACTOR _ ADDRESS LICI PHONE J TY OF MP: ❑ NEW WELL ❑FfEF'IACEilm T WELL ❑ ATONITORIND WEIA R ❑ OTHER 1P�d& C S ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CrbSSCONNECT REPAIR ❑ VAPOR EXTRACTION VVM.I Paw❑Rytslr H.P. DEPTH PUMP SET FT- FIRST WATER LEVLI FrYpE OF PUMP) ❑.OUT-O"ERVICE WELL ❑ DEOPHYHCAL WELL 0 Q SDN-RORrNe ❑DESTRUCTION: INTENDED ucc YPE OP WE'LL CoNSTRUcnON SPCCWWATIONS �L ❑SIDUST RAL ❑OPEN SO TTOM DLA.OF WELL EXCAVATION �- DIA.OF CONDUCTOR CASINO 11/T ❑ DOMESTIC94RIVATE ❑GRAVEL PAC"';'E TYPE OF CASMMTEELJPVC C DIA.OF WHL CASINO ?!� ❑PUM)CIMUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL. � SPECIFICATION O ❑ MRIGATION)AG ❑OTHER GROUT SEAL INSTAL.Lm BY 54 4caV I& GROUT BRAND NAME -N ,� �MON1T0""Z,W Ta wq i�Lj``�- GAOIJT SEAL PUNLPEO;JOY- ❑'N. CONCRETE PEDESTILL SY DRILLER:❑Y- ❑Ns APP"ox DErTH 55 -�EIe,'l" LOCKING CHESTER SO pAla i ]�w PROPOSM CONSTRUC"ONAMLUNo METHOD; MUD ROTARY MR ROTARY AUGER CABLE OTHE{t___��• I HE sy CERTIFY THAT I HAVE PREPARED THIS APPUCAIMN AND THAT THE WORK VMA BE DONE IN ACCORDANCE WITH SAN JOAOLAN COUNFY ORDINANCES,SYA7E tAVYI:,AND RULES AI REGULATIONS OF THE SAN JOAQUIN COLWIY, HOME OWNER OR ucag6EU AOEN7"S SIGMA?LME CERFIFIES TME FOLLOWING:'T CERTIFY THAT IN THE PERFORMANCE OF THE WORT(FOR VJHT THIS PEIWIT IS ISSUED,I SHALL NOT EMKoy PERSONS SUBJECT TO WORMTMAN•S CoIMPERSATHUN(AWS OF CAUFORNM-CONTRACTOR'S MRING OR SUS CONTHACTIN6 SIGNATURE CERTITI THE GOLiOWINC -1 CERn THAT IN THE PERFORMANCE OF.THE WORK FOR WHfCH THIR PERMIT IS ISSUED,I SHALL EMPWY PERSONS SURIFCT TO WDRRMAN•s COPAMOAT1pN LAWS CAIRDRMA.• E APPIIC NT M T CALL 24 HOURS IN ADVANCE FOR ALL REOUNIiD POCTONS AT 12"14SY 1123. COMPLETE ORAWINO AT LAYER AREA PRDVr0EO. Elansa xZ TltlV I�� t.T'ZQ(!!l+•!ST DKe 3y 0 PLOT PLAN'--to Scala)Sule •to 1- NAMES OF STREETS OR ROADS NEAREST TD OR BOUNORIU THE PROPERTY- 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION- EXPANSION OF SEWAOE DISPOSAL SYSTEMS, a- OSWNSIONED OLUTLOWS AND LOCATIOM OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS NRTHN RADIUS OF ONE HUNDRED FIFTY FT, STRUCTURES,IMC LUOiNO COVERED AREAS SUCH AS PATIOS,DNVEWAVS,ANO WMUCS. ON THE PROPERTY OR ADJOINING"to Pa TY. l5ee- pp Q S. e wL} osf.9Iezw�ler< o► s - 1 L DI PARIMENT USE ONLY r 1 Anplkeelen Aaampted By (� DKe 7 I I Arse Grout h»pactk-BY Oate P—P 1r0a Uan BY Dste D-t'-6-Impsatfen BY ,,,[ - 0 LTsts cammarc.:_ �, u ' /1�� 'Tt�f;�()T-w�(s-1 ACCOUNTBiO ONLY- AIDS FACS I.CODES FEE INFO AMOUNT REWITED C CASH h MOM MY DATE PowlTravrAcE REQI4ST Ntamm INVOICE IV kl7 2.2