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APPIlr"ION FOR WELLIPUMP PERMIT SAN JOAQ��AUNTY PUBLIC HEALTH SERVI. 1 ENYIh�fYMENTAL HEALTH DIVISION P 0 BOX 388,445 N.SAN JOAQUIN ST, STOCKTON,CA 95201-388 12091460-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complate In Trglicatel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDPDR INSTALL THE WORK DESCRIBEO.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAi JOAQUIN COUNTY DEVELOPMENT Trrl F,CHAPTER 9-1115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERMIES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APHe 1603 ..?OTS f-h R 5 c S +C.k&A.3 L-A PARCEL SREJAPNs 3 AC-. OWNER'S NAME L-ALrPZ A -/9 11,6 E. Ghu!Err ADDRESS SjI prA& r-4 9,&Z l PHONE 0 ZC9,9Y'e�•' �>'3 T&35 5.—,area 11irJ, #(a CONTRACTOR V EOCCN Ert..l rGH n fa )Ata AODRESs Re.,c1.,,[a.r f L;1 1 c:/ ,)5'OLUCe PHONE a /(•>rS2•Ll!!P t✓f� ADO /Sh'lLC��J(� T— REssf,a f3ta S/ f:lc dLSTA Uca IOL 1b' PIONEfj• 2 3i�i. 9'J5 SUB CONTRACTOR 7�11�eEI TYPE OF WELLIPUMP: ❑NEW WELL ❑REPLACEMENT WELL IJY MONITORING WELL aIll'11 ❑1f OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR Q E f]�� Q1L VAPOR EXTRACTION WELL/a r VAf'7 J ❑Naw❑R- I, H.P. DEPTH PUMP SET•-____FT. FIRST WATER LEVEL_- ITYPE OF PUMP) Re ❑OUF`-0E-SERVICE WELL 13 GEOPHYSICAL WELLa ❑ SOIL BORING I, B ❑DESTRUCTION: /VL R Exp l+�I eJ_l LLh �H /C ( M A. I t if J 1 CI)�lu-f VAf-z INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ') A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_-, n/..2Ic/L DM.OF CONDUCTOR CASINGO ❑DOMESTIC(PRIVATE ❑GRAVEL PACKI512E TYPE OF CASINGISTEELIPVC Pyc DIA.OF WELL CASING ^j// " A41 � ' 2 ,2)O ❑PU81JCM UNICIPAL /❑�L DRIVEN �1�/ DEPTH OF GROUT SEAL 'SST 444.ll- �(�r�Mij.)SPECIFICATION 5 b A& B ❑(IRRIGATION/AG MOTHER �A��r a",47 IDI rµ[ GROUT SEAL INSTALLED BY T GROUT BRAND NAME bort IC Ly frAaLx! e JE7�MONITORING tjVJ(TT^••/•IH�/�J `� GROUT SEAL PUMPED:MY- ❑Ne CONCRETE PEDESTAL BY DRILLER:[I Y. CIN. S APPROX.DEPTH40 Tl. LL/Af' ✓/V!-z3—f0h 6vfw'll� LOCKING^HESIERBOX/STOVE PROPOSED CONSTRUCTION1oPoWNO METHOD: MUD ROTARY AIR AUTANYAUGER X CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUBCONTRACTING SIONATVRE CERTIFIES THE FOLLOWINGS I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.• T CANT T C !/4//HO�I/1yJR$1 ANC£FOR ALL REQUIRED IN TONE AT I 4q-3423.COMPLETE URAWING AT LOWER AREA PROVI/EpO. ({ Sl9nee X �!N-" TIlI. T lI r oNe �t { POT ALAR)Drew I.See1e1 Swb 'to 1.NAMES OF STREEr6 OR ROADS NEAREST TO ON BOUNDING THE PROPERTY. 4. LOCATION OP HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.MMENWNED OUT JNFS AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. I�EF El: V Ltl I:T�I�I1 T_a7�J �A ff.rL ... TOAYC 2-11 199 Ah WGII SlScc:}i t,b:._.. 45 kl 114 Ij /l.(� DEPARTMENT USE ONLY ^/ Apptlutl-n Accep[ed BE Dne 4 ' �� Nee....... •' Groh 13 Y)AA V-1\ Det- PumP Irupeelbn By Dete D-euuctlan Impxlbn By be[- C-mmarvle: ACCO VNTINO —11: NDl FAC$ PE CODE$ FEE INTO AMOUNT REMITTED CHECK01CASH RECEIVED BY LATE PAJrIITISERVICE REQUEST NUMBER INVOICE 350 g �PIl� me2w , 7- -V 0 0 3rd,O