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F APPLICATIUM FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 9881304 EAST WESER AVENUE, STOCKTON. CA M01.388 (2091469-3420 11 ` oe` ILEF NUABLE PERMIT EftPpES 1 TEAM FROM DATE ISSUED (Complete M TdpReBal APPUCA71ON 10 14EFW BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRMEb.7109 A ICATgN IS MAD!IN COMPIiANCE WITH SAN JOAQUIF COLWtY DEVELOPMEITLEH ,CHAPTER 9-111 6.3 AND TOU HE STANDARDS OF BAN JOAN COURVI NTYPUKW EALttf GEC[6,ENVI N NT TMEHTAL HEALTH DMSION, JOB AODREMOK APN/ 0,0 �--•- 0 � ��- crrr�� '{J PARCEL 81ZFJAPN• -A R'B NAME ADORE l6 �7 PHONECONTRACTOR ADDMA@ / [ c LiCiZ2292S&PHONE�C / MIB CONTRACTOR ADDRESS • —PHONE TYPE of VYELLAnmAF- ❑ ww WELL ❑ REPLACEMENT WELL ❑ PAONFTOPWM WELL• ❑OTHER ❑ INSTALLATION ❑ WELL SY TFM REPAIR ❑ CK099-C13NNECT REPAIR ❑ VAPOR T�TTIA Tom WELL I J (]/C�� ❑NRrw g1YA.PM H,P, DEPTH PUMP 9ft� FT. FIRST WATER MEL O OP Pum" ❑ DUT-0f-SERVICE WELL ❑ OEOMIYMCAL WELL• ❑ BOIL BOM& S I ❑OE8TR0.RCTION- NTiND e O CONT I1Q11 CIFICATgNe A ❑ INDUSTRIAL ❑OPEN BO TTOd.; OIA.OF WELL EXCAVATION DIA.OV CONDUCTOR CARING O XDOWITTICIPRIVATE ❑aRAVEL PACXM if TYPE Or CA811401eTEEL)PVC OI A.OF WELL CASINO O . ❑ PUftX,%JUWWAJL ❑DRIVEN DEPTH OF GROLFT SEAL 6rMFTCAT16N ❑ IRIe0AT1OMAG ❑OTNEN OROUT SEAL NBT AILED BY GROUT BRAND NAME F 5 ❑ MONITORING GROUT SEAL PUMPED: Ely. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑YRr ❑N. 6 r APPROX.DEPTH LOCANT CHESTER @OX/BTOVE PIPE 5 C PROPONSD CONeTRVcriow DRILLING MiTHOD! MUD ROTARY_ AIR ROTARY AUGER _CABLE p I HE9E8V CERTIFY THAT I HAVE PREPARED THIS APPLICATION AM THAT THE VMFI(WILL BE DONE IN ACCORDANCE WTTsif SANJOAQUI N COUNTY omowANCES,SLATE LAW$•AND RULE6 ANO REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR Lk-ENBEO AOENT•B 900MATUMP CERtwIES THE POLIOWM!9 CERTIFY THAT M THE PERFORMANCE OF THE WOrK FOR WINCH THIS PERMIT 16 ISOUEO•I @HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPfNsATION LAWS Of CALX-OIW.1A.- CONTRACTOR'S HIRING OR SUB•CONTRAICTING SIGNATURE CEMIFIE@ THE FOLLOWINO; '1 CERTIFY THAT IN THE PERMr*AANCE OF THE W0M Foe%MACH THIS PERMrT IB IBRUED,I @H/di EMPLOY FE1160N8 SLISJEtiT TO women m-0 COM ATION LA Of CALIFORNIA.' T ANT MUST c HOLM ADVANCE FOR:W.REOMED IN: ONS AT 170@1 4M-9422, COMPLETE ORAW*M AV LOWER AREA PiROViD 0fv,w X TT1I. O.t. PLOT PLAN RN—le P-9.1 Bed. I. NAMES OF STAMS OR ROM}S NEAREST TO OR tPDL*MG THE PrvmVTTY_ 4, LOCATION OF HOUSE 8lyVAGE bISPOSAL 0Y9TEM OR F7RarogeD 2. OUTLINE OF THE PROPERTY.OIVTNG OWENSION6 AND NORTH DIRECTION. EXPANSION OF SEWAGE SW,SYSTEM, 7- DIMENSIONED OUTLINES AND LOCATION OF ALL FXI8TINa AND PROPOSED e. LOCATION OF WELES W►f'F/IN RADIUS Of ONE IN1NpI1Eb FIFTY FT, STRUCTUIIE6,41ICLUDUM COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AM WA;X8. ON THE PTIOPERTY OR AMMNNG PROffKrY p.. V oO C i 1 , It.. .'. ..: ...{.... t ..n.... • i ... C .- .....A ... :•.. .... .................. ...... ... ..... ............. ............4 . . . .:.. ... .. . r°r: . . . . . . .. :......: . Vie. :... : ......... :. .o......... .. .. : ...` . .. :......... : >... ......:.?.. ..... :: N 219917 ... . ...: .. . ...... L;iri� . UiJN7Y PU[iLIC HEALTH SERVICES _ ^ DFFMITfkMT USB ONLY IUN Aryst1o~A.. .4 Sy _jyM l' J Dme PR•RP InR$..Ilon By - �n /_•- V-C rl De.Rnsa11—4yp.{,Ilen 91• --�•�1 DM• C.mment.: ACCOUNTING ONLY: AID/ FACT PB CODFA /F�EE�I^IN'O AMOUNNTTRRUAITTED CHECI nI/A_SH(� RECEIVED gY DATE F~IIIAMAC REGtW5T NUPMER INVOICE / 3 DSO .] V *(b1 6 r/o�rg o-3 OjLf Pub-Health Serv.-Enviru.173(3M6)