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P. 1 APPLICATION FOR WELLIPUMP PERMIT SAN JOA(IUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388 S(4 EAST WEBER AVENUE, STOCKTON, CA 9.201388 (209) 469.3420 Mn!(-REFUNDABEE PERUIT EXPIRES 11TF31i FR-ow DATE ISSUfD (Comp4aF In Triolicats) APPLICATION m IIERE BY UAOE TO TUE SAN JOAOUW COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE-OR[DFSCMIIEO.THIS APPLICATION IS MADE DJ CO A-,IANCE%TTN SAN JOAOUIN COUNTY DEVELOPMENT TT)rrtL C04APTM 9.111 S,3 AND THE STANOAR)q OF SAN JOAOUIN COUNTY PVRUC HEALTIt SERVICES,ENVRONUENTAL HrtN HEALTH OnetO . JOG AOORESSIOR APN$ 616V �� n j CITY s - -/ lZi/S/ PARCEL B(ZEIADNi OLHlER•[AIAME_ ZCCI tTc.-4�/�!lLrlY� C._L�IM 2LIZy; Af)ORE56 T��. �l��(- ��` ��L"tZ .t".C✓1 Ir.o*IE, ZJ CONTRACTOR � li% f �9`��ti�-'rT (7'��l G-��/C?� ADDREea3�tc.tshu��Yir��.�tc<J - J sy/ / j c;-7� �" lYZuc$ PHO•rE, t,L• '!C J ; CONTRACTOR AO TIM SS LR.$ PNCNF,$ TYPE DF WELVPUMP- XNEW WELL © RFpL,-crwEHT WELL ;<"ONTTOaINn wELi•—� ❑ OT-HFA ��JJ Q INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO99-CONNECT REPAIR VAI`QIR EXTRACTION WELL Y El Naw D R-.l. H,P. OFTTH PJMP SET rT, FMVT WATFR LEVEL n y RYPL OF PUMP) ❑ OPT-or.."VICE WELL ❑ OFOT.IYSICAL WELL t ❑ SOIL EOmNO R ❑DESTRUCTIONi IN7Pf'IDED U6E TY VE OF WELL COHC TRIlCi}Ow CvECIFICATIOMA .mss AC ❑ }NOUSTAIAJ. ❑OPEN oo TOU DIA-OF WELL EXCAVATION ORA.OF CONDUCTOR CASINO O ❑ DOMESTIC/PMVATE ❑GRAVEL PACKJRITE TYM.Ot CAmNnIFTEELMIM D.A.OF WELL CASTNn O� ❑ PVSLJC/FR1MCa'AL ❑o,-,tN OcmF4 OF QRnUT SEAL St'CCTCICATION R ❑ IRRIGATION/AG ❑OTHER GROUT MU INLTTAIXED OY A ,*� GROUT BRAND NAME NIE X MOTCRINO/4�`� MKT t -17Un/ OROUT BEA(.RIMKO, O Y— ❑N• CONCRETE PEDESTAL SY DwLLflt:❑Y.• ❑N. ,S A PPRO 2,0EVT14 LOGKIFIO CwEBTER IIOY,%TOVE PwE S PROVOCED COKSTRUCTTOX MOWKO P$ETHOD- MLIO ROTARY AIR F"T.Sry-- AUC-fR CA11LE OTHER vl,�� rw�i lc {?l- (-4wtu)147 `f .✓e&5 #PsG i� I HEREBY CEZTTIFY THAT 1 14AVf PREPARED YMP APPUCATI17•I AND THAT THE WORK NASI KF DOSE IN ACCOIOAUCE WITH SAN JOAOUIN COUNTY ORDINA14CE4,STATE t�Vdg_AkO RULES-0 REGULATIONS Of T"F BAN JOAOUtN COt7MrY. NOW CMINFR OR LIC`FWAD AGENT'S RK,SNATURE CERTIFIES THE FOLLOVAm(j,-1 CFRT*Y THAT IN THE PERFORMANCE Of Tart Wow FOR wanCIV TUIS PEnx*fT M ISSUED,I SHALL NOT MKOY PERCON9 UUBJFCT TO WORK.4AW 9 COMPfUVATION LAWS OF CAt1FOMOA- CONTRACTOR'S H"NO OR BUS-COMRACTwG SIGUATUAC CERTIFIER TUE FOLLOWING; 'I CFITTFFY THAT M TUU PVWORMANCE OP THE WORK FOR WHICH TMC rtp.FTT It IRRUED,I SHALL EUPLOY PERM--STMJECT TO WCOMIMAN'F COMPCWMATION LAwg OF 7 CAUFORMA,' THE APPLJCANT MUST CALL 24 NOURA IK AOVANC{FOR ALL REQ(""INLP{CT)0K8 AT 12OAI A4t*-%a". COUTT-ETE DRAWING AT LOWER AREA rTb-Mo- / O+a•.•d K T.F. v S�!C%/-/i �T-- O•• - 6 o , PLOT J'L.Aw 9.•I.1 1-.,- I. a,.I. NAMI tS Of STREETS OR ROAOS NEAaEOT TO OR SOWMINU THE pM)CEPTY. A. LOCATION OF UOUSE SEWAGE OIBFVIfAL SYSTEM OR ITIOpOBED .^. OUTLINE OC TUE PT1OPEWTY,GIVING DIMIkRIONB AND NORTH OtMCTION, EXPAy670N OF SEWAGE DISPOSAL OYRTEMB. 3. DMAENSIDNEO OUTLKR:e AND LOCATION OF ALL EXISTP+O AND PROPhBEO t. LOCATION OF WELTS WITHIN RAOttUS OF ONE HUMMED FIFTY R. STPVCTVRES.0JCLt/O1NO COVERED AREAS SUCH Aa PATIOS,DIOVEWAYS,AND WALKS. ON THE PROPERTY OR AOJORaNG PROPERTY- ...... .i, ....V. / OEPAAT74MT USE ONLY A•OF-0t A•e•ete,I BY T/ D•I• .� L.�n, A,r �, LL O,w Lwc.b..DT - (;isi.7!Y.--. On• F- .� C';�� t4sap W.p-t-eY D•r• o+.t.awrw•L�•e•tty.0Y D'I• ACCOUNTING ONLY: AID$ It— FIE CODES FEE INFO AMOUNT PATTED CHECK$IC$6H i RECpVED BY DATE PET 11,11HIVICf REQUEST Ntr"ER I-OtCE Pub.Health Sere.-Err iro.173(31K n.