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I I,1 APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 95201.388 (209) 48=-3420 NON-REFUNOARLE PERMIT EXPIRE! 1 YEAR FROM DATE ISSUED MompIfLE if Trip ints) APPLICATION IS HERE BY MADE TO THE RAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANICE WITH BAN JOAM!W COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUINCOUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORFSSIOR APNS Z= go C(TY PARCEL SIMAPNf_9 e�Q OWNER'S NAARE ADDRESS ��^•r�� JJ/��Y /`-/�J/ �Jo/��.IF4HONES CONTRA TOR, ADDRESS ) G+1/lLICI-7`J�"�P�.IONE BUB CONTRACTOR_ ADDRESS UCI TYPE OF WELLIPUMP; 0 NEW WELL D REPLACEMENT WELL D MOWMFUNG WELLS ❑ OTHER ❑ INSTALLATION D WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTWN WELL S J ❑N—❑pla'. H.P. DEPTH PUMP SET FT. FFTST WATER LEVEL o ITYPE OF PUMP) /` -f.- f �i1' !//X 15 ❑ OUTOF-BER/ICE WELL ❑ GEOPHYSICAL WELL 0 ❑ SOIL BORIN�F,y/••� ,i�l'/Yf�'L �© STRUCTIOM / _ DIED USE _ CONGTIRLICrION SPECIFICATIONS A ❑ I.DUSTRIAL D OPEN BO',TOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTORCASNG D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISQE TYPE OF CASINOISTEELNIVC DIA.OF WELL CASINO D ❑ PJBLRCIMUNICIPAL ❑CaVEN DEPTH OF GROUT BEAU SPECWCATION R ❑ IRRIIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY C.MUT BRAND NASA[ E ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑Ne CONCRETE PODEBTAL BY DRILLFR:❑Yw [lift 5 C APVMX_DEPTH _ LOCKING CHESTER BOXISTOVE RPE S PROPOfED CON111411UCTIONMAILUNO METHOD: MUD RO"(ARTY AIR ROTARY AWEA CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AGO THAT THE YYOW WALL BE DONE IN ACCORDANCE WITY,BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND C" REOULATONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOVA'NG:'(CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WOIO(MAN'S COMP(NfAT(ON LAWS OF CAUFORWA.' CONTRACTOR'S HIISINO OR SUB-CONTMCTINO SIGNATURE CERTIFIES THE FOLLOV��HAT HE PNCE OF THE WORK FUR WHICH THIS PERMIT IE ISSUED,1 SHA:L EMPLAY PER6AN9 EUB.IECT TO WOMIXMAWf COMP fAT10 IALAIB OFCALLEDRIMU N ADVANC[POh ALL REOLlfIi®WfP�T10 AT(ZM 4ff.1423 COMPLETE DRAWNC AT LOWER AREA". Blenaa X �_ TMe Wte PLAT FLAN o ew to Sole)Serie 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE 04SPOSAL BYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING OIMENSIONS AND NORTH DIRECTIDN. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DWAENSIONED OUTLINES AND LOCATION OF ALL EXMn WG AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,NCLUDWO COVERED MEAS SUCH AS PATIOS,DRIVEWAYS.ANtI WANKS. ON THE PROPERTY OR ADJOINING PROPERTY. :....:.....•.....<. . ,:.. . ... . , .......... .... .....:............................ ....... PaYNFENY' .... .:.. .:. PUB N•,1 .. L ENVIRON ENUC T BE=RVtC� . . . ... •: .......:.....+... ....... --- ..;. ...............,......c...... ..........: ..p......:......i.....,... ...,..... ...........s....... EAL7fi D11fISIQ�;•' 4C Mfilr ..i......:.. ...................e.............. .. ..........o.... ....... .. .. ... /'f�RyI .......i.............,i........................ .............<...... ... 1 I� j�///A■ -. ... .:.....a... .. .. 41 e i '411..... , ..:.. .:. r ............... ........... •V ...... ....... .......... ...... . ...... • .j. ............... ... ............................ ....... ............ ................... .................... ........................ ......... .................. ........... ........................... . .......................... ....i 4Q DEPARTMENT KNE ONLY Application A c"Fbad BY 1 Data r `•"'' Y [./ G,eVL Impsullon BY Dam P"P kwoombon BY Date Deahvotlon Impaction BY_ Daee cz.Z/ r ACCOUNTIN9 ONLY: AID/ FAC/ PE CDD':JR FEE INFO AMOUNT REMITTED CIRC ASID RECEIVED BY OATI P~Tt$OMCE REOUEST NIRMa1 INVOICE ai 7 ai 9 S" S `?3 5