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APPLICATIUN FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES l U ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 � � �%«,��/M� � �� (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompbb In Trlplkrts) r` ' AL" IC. AT I6 HFOE BY MADE TO TIIE SAN JOAOUIN COUNTY EOR A PEnMIT TO CONSTRUCT ANDKIR INSTALL THE WORK DESCRIBED. THIS AM'LIC AT ION 16 MADE IN COMPLIANCE "III SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION, JOB AGGRESS/OR APNR J`I .J LL�yy,(,/ - C'J�� -( �� CITY PARCEL ` PARC.EELL SIZE/APN/ �1 ) L��7 OWNER'S NAME�I� V /A� ,E��✓/y�N ADDRESS .d'C-JSt LI��.1 MIONEI r%C1 �1 � 3S % / 07 C I'c ( (T n CONTRACTOR Ems,(( L�.C�(� V Y U(V j'�1L� (Y"}[ ( .� (l '(N tiADDRESS `V�1 C I 1� I � C1t 1(('1tUC/ (C)S 1 ] Ij�� MIONE R OO 1`F-3.31C.�1 SUS CONTRACTOR—7Lh.C_ 11 "k- 0-\ ADDRESS I1"=� W �1Li'n UCRS IZLIU CJ MIONF.I ✓'CFIi01 �` ' I Z TYPE OF WELMOmr; ❑ NFW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL R TITER ❑ INSTALLATION ❑ WELL SYSTEM FIEPAIn ❑ CROSS CONNECT REPAIR ❑ VAPOn EXTRACTI N WELL R J 11Naw11n—i, H.P. TERRA PUMP SET FT. FIRST WATER LEVEL O R VPE OF MIMPI ❑ OUT -Or REnVICE WELL ❑ OEOMIYSICAL WELL / FOIL BORING_ S ❑ DESTRUCTION- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM VIA. OF WELL EXCAVATION DIA. OF CONDUCTOn CASINO O ❑ DGMFSIIC1MIVATE ❑ GRAVEL PACK/BTZE TYPE OF CASINO/STEE.IA'VC DIA. OF WELL CASING p ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A ❑ IROm ATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ❑ MONITORING GROUT SEAL FVMPED: E&Yw [IN. ❑ [IN, �1f `r�"i CONCSETE PEDESTAL BY DRILLER: Yw APTOX. DEPTH LOCKING CHESTER BOX/STOVE APE PROMPITO CONKTRUCTTONIDRILUNO METHOD: MUD ROTARY AIR nOTAnY AUGER CABLE OTHER l_C - III I HE FRY CERTIFY THAT I HAVE E'REPAREO THIS AM'LICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNED On LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S TIMIB NG On RUB SIGNATURE CERTIFIES TIIE FOLLOWING: ' 1 CEFFI IFV THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'/ COMPENSATION LAWS OF CAI IFORNIA..�" THE APPLICANT MUST 24 HOMO IN V/1NCE FOR ALL BEOUREOTIKSKCTIONS AT 12001 4BSJ 123. COMPLETE DRA MNO AT LOWER AGFA TOVIDFO. AIpnM %_I Irl CL.I�I—/L _ �I TIUe L]L JL,L�-C—� . ONe._ `�-- C) (1 _1 PLOT PLAN ID, wr, Ie Sa Nwl Swelw le 1. NAM(A OF STREETS On ROADS NEAREST TO On BOUNDING T14E MLOPERTY. R. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On 1'RDPOSED 2. DOTI.INF OF THE PRIIMOTY, OIVINO DIMENSIONS AND NORTH DIRECTION. E%PANRION Or SEWAGE DISPOSAL SYSTEMS. ;I, DIMENSIONED OVTLINFA AND LOCATION Or ALL EXISTING AND TOPOAETI S. LOCATION OF wEtis WDIIIN RADIUS Or ONE HUNDRED I IrTY ET. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE rT10PE1TTY OR ADJOINING MLOMnTY. =1=1=1=f-1=1=1=1=1� Zf=1=1=f=1=1=1=t=1=1-1=1=1 1 1 1 1 1=1=1=1=11=1=1=1=1=1=1 1 1 1=1 1 1=1=1=1 1 1 ween „IL..............e,.,.I. 5 J 3 t s • • _ 5 i � •i,I v' i I - IJ I__I H _J 11 i 1 m p 0 F; p2,0010 v � l D DEPARTMENT USE ONLY Annlla Nlen AeeaPleA PY Owlw V _ ^ 0 6 Mu . 0,— Impar Non Br Owte Pump InEp-11— BY DHe D•wlrn•.Ilen 1— 11— BY Pub. Health Sew. - Enviro. 173 (1/97) � �1f `r�"i Pub. Health Sew. - Enviro. 173 (1/97)