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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER (Complete In TPIpReELEI APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRICT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11\15.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY MOM 14EALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBAODRSS,DRAPNO S6O [,&4o41LNol Yaf1C �!', CRY M�(w1 ��1 IPARCEIL BRF/APNI; 6C L1r 19-46/� OWNER'S NAME �/�� L11 NS ADUMBIS 3�jO0 YC+1.rs'aN -424/ Sa..1q (,Lefe�IWNEI LIOK-7�.�' 42"b CONTRACTOR A-V4 INSSe]GV.fey LN+, ADDRESS H,q L.w f2LI m A�,fAOA.EHJ11LIC# PHONE I . 57V'222I SUBCONTRACTOR F.S�M 1_`^"`c0 v..``U.1 ADDIIESS Me IeK)$GY PHONE# Z,6,1•'771 3$Zp L/GE cr Srr.,nRS C,4 TYPE OF WELUMIMP: /❑ryy NEW WELL ❑ REPUCEMENT WELL ❑ MONITORING WELL/ ❑ OTHER L6 INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELLI J ❑New❑RmWr N.P. DEPTH PUMP SET—FT. L.Ek WATER LEVE �J O MMPI OF MPI ❑ OUTCF-SERVICE WELL ❑ GEOPHYSICAL WELL I Ek SOIL ROBING J r I ` B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INCIJSTRAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ DOMESMJPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINORTEMV AJ/"1" DIA.OF WELL CASINO D ❑ PURLICMUNMIPAL ❑DRIVEN DEPTH OF GROUT SEAL !LJ r SPECIFICATION R ❑ IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY LS- , GROW BRAND NAME E ❑ MONITORING 1 GROUT SEAL PUMPED: ❑Y� CONCRETE PEDESTAL SY DRILLER:❑Yr [IN. 5 APPROX.DEPTH Y F4- LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONETRUCTIONORILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APRICATKIN ANO THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.ANO RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED.I SNALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTNO SIGNATURE CERTIFIER TNS FOLLOWING: -I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA.' THE AFPICA�NT MUSTjjj CALL 24 HOURS IN ADVANCE FOR ALL REQlmlm INSP[CTONE AT NISEI 448.1422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Bgned X I TI". "BA Q/Y1. D.t. ! I L tt J ROT PUN Oreo Ie a W.)U.I. 1 'to 150 r 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.ONINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSONED OUTLINES ANO LOCATION OF ALL EXISTNO AM PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Ff. STRtMTUREB,NCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, WASTEWATER -- _.T GP AREa TREATMENT �� ( ;0 "�, LINE YY- / COMPOUND y MAINTENANCE UMP STORAGE SO STORAGE ORAGE / •� m � PARKING •` / ABOVEOP,OUNO�'• PROPANEIANK X /�/C v•s TANKS MW-3 P 1, 541 ` \`• EMPTY DRUM / / / �.••.` �,/� 570RACE COMPOUND COMPRESSED ICE GAS CYLINDERS `f N AP FFIILTRATIONN > / ` �•. - / .`SYSTEIA, STORAGE 60�/\OFgCE CHEMICAL %.% AP.CHME *-'—MACHINE STORAGE o%, STORAGE AREA Y SHOP HAZARDSTORAGEI� STORED `• COLD MACHINERY Sa HYTROL CONVEYER STORAGE i4 ' COMPANY MW-6 j 1182 j UNSURFACED AREA / / PARKASPH LT (EMPTY LOT) CAP, DEPAATMEKT USE ONLY AFelleWlen Aaey1M Bv,-. � OH. U Mr �, v OreN Impmlbn By Oa. Pump In.PsLen By D.Is Dabwtlen ImPeelbn 1 D.te cemmse.: /SOL ( P l T- 521E ACCOUNTING ONLY: AID# FAC# PE CODES FRINFO AMOUNT REMITTED CHE MASH RECEIVED BY DATE PDMITISERVICE REQUEST NUMBER INVOICE !.DI '5 2