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APPLICATION FOR WELLIPUMP PERMIT S IOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201 1209) 4883420 i NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM RATE ISSUED IComploto M TT1pNEete) _ •4. APPLICATION IS WERE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS E IN AMCE WITH SAN JOAQUIN COUNTY DEVELOPMENT 'TITLE,CHAPTTERR 8-1,1/11'6.3 AND THE STANDARDS OF BAN JOAQUIN CQVNNTT'Y NBUC�HEALTH SERVICES,ENVIAONMENTAL HEALTH WAMRN. JOB ADDRESSIOR AN,-2:"--,,/��/ — J I /'/��e� CITY✓ �/(/Oh PARCEL SILFIAPNp L OWNER'S NAMEJ�y/4��L/}/�'.rT / __ ADDRESS TJ/�Q) 11149 ea PHONE CONTRACTOR J/L�//L!/A'I { X/l�Iiu7l�Jy1 7�P AOOPEBB AA I+.ls'M .Gl. L1Cy�?J�B pN NE ' SUB CONTRACTOq '7 r-1 ADMESS tuts PHONE# TYPEOFWELLMUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# .�OTNER�O/C ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ C9088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ ❑N.❑Rt v, H.F. DEPTH RUMP SET—FT. FIRST WATER LEVEL 0 RYPF OR pUMR rI--tI ,y 11OVY•pF-SERVICE WELL I.J OEO PNYBk:AI WELL F Jql 901E SORINa�O/� , ��/iL✓n p ❑OECTRUCTION: INTENDED USE TYPE OF WELL CQN&TRUCTION SPECIFICATIONSA [IINOUSTRIAL ❑OPEN BOTTOM CIA.OF WELL EXCAVATION '41-6 /AChyf DIA.OF CONDUCTOR CASINO NAVY D ❑ DOMESTIC/RSVATF ❑GRAVEL PACK/SIZE TYPE OF CAsINOISTEEVPVC D e bIA.OF WELL CASINO O ❑ RUBUCIMUNICIPAL �❑l DRIVEN � / DEPTH OF GROUT DEAL JF/ SPECIFICATION ,ry ❑ IRRIGATION/AG OTHER&ll VP(�, R y li GROUT REAL INSTALLED BY GROW BRAND NAMEE XMONITORINO /+/ Ogom DEAL PUMPED: ❑Yw 13N. CONCRETE PEDESTAL BY DRIL1FR:1'113 Yr ❑M# S APPROX.DEPTH �. P/ T T• ,0 tACKINO CHESTER BDXMTOVE RPL 8 PROPOSED CONSTRUCTIONANCLUNG METHOD: MUD AOTARY AIR ROTARY AUGER CABLE OTHER I NMSY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOPK WRL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAURA,AND RV ND RFOULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW ICN THIS PERMIT 181FSVED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'4 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIIONG OR SU"ONTRACTINO SIGNATU RRRES THE FOLLOVANOI -1 CERTIFY THAT IN THE PERFORMANCE OF THE wow FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMFLCY PERSONS SUBJECT TO WORKMAN'S COMPENSA N LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL HOURS FOR ALL REQUIRED��S AT4 011140114433. COMPLETE DRAWING AT LOWER AREA PROVIDED. (�f N/ r PLNG DEAN IMPIO t#SwNI welt ••It•y,2(Z 1. NAM SOP STREET11 OR RY,GI MNG DIME TO OR BOUNDING NOR THE PROPERTY. 4, LOCATION OF HOUSCEWA E DISP E AI-GY"t SYSTEM OR RIOP06116 E. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS ANb NORTH DIRECTION. EXPANSION OF SEWAGE bIBFVBAL SYSTEMS. ' T. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6, LOCATION OF WELLS WITHIN RADIUS OF CHL HUNDRED#PTY FT, STAUCTUAEB.INCLUDING COVERED AREAS SUCH AS PATIO@.DRIVEWAYS,AND WALK$. ON THE PROPERTY OR AOJOININO PROPERTY. iso A-JF, ... , ; .. ... Y �F..��M'�4 • I ..:�,., a .5 �, p N, 9, 1 A. : 1/ . ; V L� !. o; . I .. o .. ....> .. J /t 3 t .. i......,.. .....:... . . ...... .... ' .... > ......;Q 111 .. ,. i.. !� v I. Y r o : . ..r.. ...t.. . . ... .,.. / J :J 1. . ' .. ., i. i.. i r .... , 1. .. ) q t s.._ I IIS2SJ �' o(Ale DEPARTMENT List ONLY AP#HmWB A..Wi d 6, T Sete ///Z��An. . Grout InPpeotbn BY qqq p Otte PV IMP7COM BY - IF DMt�tleN lnpwtbn � 1L� .. h DttR Z ��A 1 Cemmenu: �' ACCOUNTING ONLY: AID# FAC! PE CODES PEE INFO AMOUNT REMITTED CHECKFICASH RECEIVED BY DATE PERMIT/solvoce REOUEGY NUMSAM INVOICE