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SAIDPPLICATION FOR WELL/PUMP PERM AQUIN COUNTY PUBLIC HEALTH SEOCES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NDN-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TrinDestel APPLICATION IS HEM BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WOW DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TILE,CHAPTER 9--1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH1 SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN/ 441 w fsT {�N.{(L'[P/[- w A,( CITY A)-voc✓TVH CA PARCEL SIZEIAPN/ OWNER'S NAME DoH RODBE12S ADDRESS LlyoO MnAsJ'LEJ r>.�o 9$'336 PHONE 0 4G4• S�$0 1 sir 7v7374 430cJ CONTRACTOR WC0bWA1V:, DILI"j C, ADDS E66 BoX 336 Rto JLSyT CA LICA 7100.7x1 PHONED PUB CONTRACTOR ADDRESS UC/ RHONE/ -- h c TYPE OF WEIR/PUMP: NEW WELL 11RER.ACEMENT WELL XM0NRI RtINO WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 J ❑New❑R .I, H.P. DEPTH PIMP SET—FT. FIRST WATER LEVEL O IT YPE OF PIMP) ❑ OW-OF-SERVICE WELL ❑ SEORIV6ICAL WELL! ❑ BOIL BORMG B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS tl B INCH 5{CE'LA 11 INDUSTRIAL ❑OPEN BOTTOMpp DIA.OF WELL EXCAVATION I$�g„ DIA.OF CONDUCTOR CASING GI O ❑ DOMESTICIPRIVATE XDRAVEL PACKISIZE 4 3 5AAip TYPE OF CASINOISTEELI SP-. SO DIA.OF WELL CASINO NC4 O ❑ PIBLICOJUNICIPAL ❑DRIVEN OEPTH OF GROUT SEAL 17 6�.� SFE!! SPECIFICATION 5G.4 .K1J R 11IRRIGATIONIAO 11 OTHER GROUT SEAL INSTALLED BB,V 'T13F .P_ GROUT BRAND NAME [9.• E �[.]I MONITOFUNG GROUT SEAL FVMPEO: qI Vu [IN. CONCRETE PEDESTAL By ORILLER❑Yu [IN. S APPROX.DEPTH LOCKING CHESTER BOXISTOVE RPE S PROPOSED CONSTRUCTIONSXNLLING METHOD: MUD ROTARY AIR ROTARY AUGER__CABLE OTHER 1 HEREBY CERTIFY THAT I HAW PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOVIN COUNTY ORDINANCES.STATE LAWS.AND RULES ANO REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE KWORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,I SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY MORMONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICAANT MUST' CALL 24 HOURS IN ADVANCE FOR A REO INSPECTIONS AT 120111400A 122. COMPETE DRAWING AT LOWER AREA PROVIDED, SI.—I x/�/ �G+/ n I. G10nl YYZd G7—S fY/N/✓AG POT PAN IOIew to Betel Baels 'm 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPTIT V. !. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF TNF PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND RROPOSEO S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED RFTV FT. STRUCTURES,INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. 1�.cKv.� W AT'TkWEI� _�AtP '. _. _.. '._.... _. .. _....... jil DEPARTMENT USE ONLY APPllvellen Auepled BY ��r ll `Y Vll'�V Dele � Aru AroW IrnveeSen By Oete Pumvlroveetlen By Mt.— ACCOUNTING ONLY: ND/ FACT PE CODES FEEINFO AMOUNT REMITTED CHECK//CAAH RECEIVED BY DATE PERMITISERACE REQUEST NUMBER INVOICE 1221 / / I Pub.Health Sew.-Enviro.173(1/97) 4