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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX U6, 445 N. SAN JOAQUIN ST., STOCKTON, CA 85201.3=11 (2091468-3420 RON-REFUNDABLE PERMIT EVIRES 1 YEAR FROM BATE ISSUED {CSIIphts in TroUssiO APIICATLON IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AMWOH INSTALL THE WORK DESCIVOW.THIS APPLICATKM I$MADE IN COAMPLLAHCE WITH SAW JOAOURI COUNTY OEVELOPMENT TITLE-CHAPTER 8.1115.3 AND THE STANDARDS OF SAN JOADUIN COUNTY-}IPLMW HEALTH SEFIVICES,ENNIWNMENTAL HEALTH MASIOM JOS ADDIES&*A ANN. 1 l Q t ' /✓�-/�f� PARc9. E/AwN. CITY od ,Z5 L't ke 5n rf1, 369—l yl OYVNE R'S NAME it ADDRESS S C� ,I+� T1IDNEJ CONTRACTOR��[/1l :�1 4=!�t l.�r'��'1 aLl-1Gbi!CII /•�-G('l l-[JQ��I ADDREYS 1�71.d�r{� !..95ca PHON�fT SUS CONTRACTOR EahAOORES62 365-Wi rao.,SlocA ruca-5712162-PHW'E l� 71-2- TYPE of wELLRLIRw: ❑ NEw YYEL!_ ❑ REPLACEMENT Well. MONITOIWNO WELL+1-&iL--7 ❑OTHER ❑ INSrALLATKON ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑VAPOF'1 EXTRACTROH WELL E 1 ❑N-0 Repdr H.P. DEPTH PIMP SET FT. FEW WATER LEVEL O fTYPE OF PU0.fP1 � ❑ OUT-01`•SERVICE WELL ❑ GEOPHYSICAL WELL P ❑ SOIL[OIINO II C7"DEHTRUCTfON: ri l� M k/-i A0 `' TYPC T TYPE OF CONY IYI ,q ❑ INDUSTRIAL ❑OPEN ROTToM DIA.OF WELL EXCAVATION ' DUI OF CONOUCTOR CASINO D ❑DOMEUTIClPIVATE ❑GRAVEL PACK-Miff TYPE OF CASING.MTEEUPVC 'vc 04l OF VNLL CASINO 2-- ISI G D ❑ PURlICMWr*CWAL ❑DRIVEN DEPTH OF GROUT SEAL , IF — wmiicATRON R ❑ IIfWAnIN ONIAG ❑OTHER GROUT SEAL STALLED BY jErc4lr,kc-A GROUT DMND NA&W E ❑ MowTOFA NG 161 GROUT SEAL PUMPED: ❑Y. ❑Ne CONCRETE PEDESTAL 6'Y INBLLM Y. Elk. S ` RMPROR,DPTH !y LOCKING CHESTER SOXASTOVE PPE S PROPOSED O0N6TF=TI0K/DiRUNO METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE —1 - I FIB#BY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOIO'.WILL YE DOLE V4 ACCORDANCE NRTH SAN JOAQUIN COUFiTY ORDIMA.MCES.STATE LAWS,AND MIN AND ` REGL11•ATX)NS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEfFDRMANCE OF THE WORK FOR VMICH THS PBOfT IS ISSUW,I SHALL NOT ELIPLOY PERSONS SUBJECT TO WOF"AN'S COWIE NSATIOM LAWS OF CALIFORNIA.' CONTRACTOR'S HMO OR SUBCONTRACTIKI SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE FE -Of*AANCE OF THE WORK FOR WHICH TITERS PFAlKr 16 MMI ED,I SHALL EMFLOY PERSONS SUD-IECT TO WORIOMAR S COMP@MALTION LAWS OF CALIFORHA-' THE APPICANT P"TT �24 HOUM IN ADVANCE PW ALL REQUITED INW'WTLONS AT(2091409-2422. COIMRM DRAWING AT LOV&S AREA RLDVIOW. Signed qL"J O_ 1'If7YR Tive �I-a0G.[Jf' �ul.�2X�lt�s01^ D.I. 1 O PLOT PLAN Pham M SALMI Saab 'to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4_ LOCATION OF HOUSE SEWAGE OISP'OBAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GLVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SIPWAOE DISPOSAL BYSrDAS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6._LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DAVHYAYY,AND WAll". ON THE PROPERTY OR ADJORNING PROPERTY. .....o......:.....i..... .... .. ... .�.. .....i....... .. .. ... .. .. a ...... ....... ......:.... --._. .. _ ...;.........,. ......... ..y......S.r..r... ... .. ��.... ..6....• - ............:... ..:.. ... J.. .. .. .................. >..... .. ;FAITH.......; "r .......... ..... r -R Ili...sCnV CSS'. i .......... vt DEPARTMENT USE ONLY Appff—k-Aaaaplad 8Y Date Area OMLA Irrpaotbn BY Daf Puny irpmt w 6y Drtruef" ItDate Cammarrta: AQOOLMI ING ONLY: Ab/ FAGHr PE C40056 Rif INFO AL40UNT ROATTm CHECKJICABN RKMWD BY DATE& POVATI6DLVIC[REQUEIT IUMEM IIVOp■