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APPLICATION FOR WELL/PUMP PERMITCjf SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION .` 304 EAST WEBER AVENUE, STOCKTON, CA 95202 Y-L '3t g " (209) 468-3420 `kzLl'� Q�tlay1 ti �/ NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE 13SUEO 6/J �C/ kICampMU In TrIReH�I P1}it�jF `I- A !CATION 19 HERE MADE TO THE SAN JOAQUIN COU IT TO CONSTRUCT ANDIOR INSTALL THE WOVE DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAGUIINnCf}UNTY DEVELOPMENT TITLE,CIIAPTEER 9-1 1 I G.3 AND THE STAN p S OF BAN JOAQUIN COUNTY PUBLIC HEALTH BP.RVICES,ENVIRONMENTAL HEALTH DIVISION, JOB An R SSIDR APN# -�t yl$, br�l [•-1 D j f b!-O,l B-d� lOf"- fb r � CITYS� +� ti •PARCEL RIZEIAPNF_ OWNER•@ NAMEy7L'I.] G cfD-'t ny,I'Iv Ant-ESe C^ J� �t'1�,q� n _�,r'�rl-,��9.,-y+tiSa_\I�-�C`I��HDUE IF�ZS—31'f-G980 CONTRACTOR Sr ,v' • c-,a ) gi58- ADDRESS .y�� LICJ_ FMONE 0 SUB CONTRACTOR k-�l F—f 11.. Y t'A-s Ya 2, ADORESS.Lt7 ZSI M�!f�a--e_ SCS UCS 6t�k�_C'J PHONE 19LE-_� TYPE OF WELUPUMP: ❑ NFW WELL ❑ REPLACEMENT WELL ❑ MOWTORINO WELL A ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1 J ❑Nvw 2 Repelr M.P, DEPTH PUMP SET Fr. FTTLST WATER LFtrfL O {TYPE OF PUMP!"7 I] OUT-OF-SERVICEWELL 13GEOPHYSICAL WELL II 1:A<SOIL BOMWI t �I ,F�� g X.7OESTRUCTION•i (^-11 L-1 f�{.[ 4 II PL-" tL i -� rz4.1"-D 6-rC_U'1n INTENDED USE TYPE OF WELL COHifRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM 04A.OF L+II OIA_OF CONOUCTORCABINO 11 ❑ b0MESTICMRIVATE ❑GRAVEL PACKIARE TYPE OF C ASINOIGT EELIPVC DIA.OF WELL CASINO D ❑ PUBLIC(MUNICIPAL ❑DRIVEN DEPTH Of GROUT REAL Sr4CIFICA1ION R ❑ 1RRIOAT,0Nr/1GOtHETi�. � GROUT SEAL INSTALLED BY 31IOUT BRAND NAMF F ❑ MONITORNO y + GROUT REAL PUMPED: ❑Yee (IN. CONCRETE PEbELTAL BY DRILLER;❑Yr [IN. 5 APPROX.bEPTH JE"O Z LOCKING CHEATER BOXISTOVE PIPE _ S PROMRFFI CON@fRUCTIONfDWLUNG METHOD: MUD ROTARY AIR ROTARY—AUGER _—CABLEOTHER I HEREBY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AN6 THAT THE WORK WILL BE DONE IN ACCORDANCE W11I1 RAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RALES AND RFAtRATION9 r)F THE SAE!JOADVIN COUNTY, NOME OWNER OII MEWED AGENT'S SIONATURF CERTIFIES THE FOLLOVANG:'I CERTIFY THAT IN THE PERFOnMANCE OF THE WOKS FOR WI11CH T HIS PEflMIT 19 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWB OF CALIFORNIA.' CONTRACTOR'@ HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOW)WING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR[FOR WHICH THIS PERMIT IS IRSUEO,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENBATION LAWS OF CALIFORNIA.' T A� CALL=+f HOURS IN ADVANCE FOR ALL REQUIRED Im9WTTONS AT 12051444-3423. COMPLETE DRAV^ANG AT LOWER AREA PROVIDED. 1 L Sty"-d %_ _ _- _, _TkUe ! 4�SC�-f p1�_� Dole_11_-"O PLOT PLAN Dow to 6"Id"I 11e21e 'te_ �( T. NAMFS OF AFRFFTS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMFNRIONEO OUTLINES AM LOCATION OF ALL EXISTING AND PIOPPOBED S. LOCATION OF WFLI_@ WITHIN RADIUS OF ONE 4UNDhfD FIFTY FT. �- STRUCTUIKS.INCLUDING COVERED AREAS SUCH AS PATIOS,DW VEWAYS,AND WALKS. ON It%PROPERTY OR ADJOINING PROPERTY. iEF f r L •`� Er��s 3 1= 5 y e /�"��;�j;��,c,�-t �Llw T^ .l ti+;,G -f,Ittil"} _ Li-Jt. •1 /�� /I �p y'=y Xc�a:�H{f;t�'�,C,,I may+ gl '•r�Z".Y., -?�.� r.. y � :*-c'wF't ' v;^''' -= �� ,.�3�tiI�F-7"�'-I '.i'c':' 51'4'e 0 V70 Y �k-'LIGSR�W�i . � k{f�'m�' C` f � u Cri AIrJ� tic ,JIIvC;u,Jr, ;Y rrt i llr'� NV1R0 ��FLiNI(JIJI�: :,, 1 aust�c E N vL1EN ' `. DEPARTMENT URt ONLY I ApM[re:4vn Aeonpewd By, bel• Arne (3—g 1mpHtctlon By bete Pvnp Inepeetrerl By _ Onto Oe.turtlnn IMne�Hlen flr_ [ - Oto cn.mm�,x.�_- 7.' � I f +Ll �3 .C'L.�^„ � f� C�S�' cA✓:�. t✓�Q- F; r'� L�+i._ ACCOUNTING ONLY: A,ON FACIP PE COOEe FEE INFO AMOUNT REMITTED C14ECKIICASH RECD BY DATE FEIRMI7 RMMCE REQUEST NUMAt R INVOIcE �- SO i---& `=- 0 ass I'l i Pub.Health Serv.-Enviro. 173(1 J97) ti.