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•PLICATION FOR WELLIPUMP PERMIT• O D U SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES Q Q y p ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 ( 468-3420 /� ` ` N5M•REFUMUpSIE PERMITRMIT EXPIRES 1 YEAR FROM DATE ISSUED i 0- � (CompletB in TrIpIkBRI APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMA INSTALL THE WORE DESCRIBED.Title APPLICATION 16 MADE IN COMPLIANCE WHIZ BAN JOAQUIN COUNTY DEVELOPMENT TEELLE.CHAPTER 11-1/ T/, 1)15.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEATH SERVICES,ENVNIONMENTAL HEALTH DIVISION. JOB ADDRESSOR AP�NO J' �(i'. .J L' p / ?" -) CITY/T,-,? '7PARCEL RJ LSIZE/AF OWNER'S NAME I�I-r- Y/,/}�'.�YI -4d y[1/.JIrlVe,"I J,[7 ADDRESS C9UpY/�yp YDl/Gn/ ��L ry/ ,RIONE R CONTRACTOR L C>'..J/I'lI PSI/TZD JfeYUIC'u- ADDRE89 n%G' / `GY.!✓//)N!c WLL./t UCI V�o SY PHONE/ W1 SUB CONTRACTOR ADDRESS r�tt�fi/•/ y UCI RHONE I TYPE OF WELLNUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER (T''^ ❑ INSTALLATION El WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR C1 VAPOR EXTRACTION WELL/ J ,J Ilew❑Aep.l, H.P. DEPTH PIMP SET/a�4-FT. FIRST WATER LEVEL O HYPE OF PUMPS ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL A ❑ 601E BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 13 INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTICONGVATE 11 GRAVEL PACK/SIZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CASING O ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROW SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITONNO GROUT SEAL PRIMPED: ❑Yr ❑N. CONCRETE PEDESTAL BY DRILLER:❑YM ❑Na 5 APPROX.BE"" LOCKING CHESTER BOXISTOVE PPE S PROPOSED CONLEAMTIONaNBUING METHOD: MUD NOTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT 11LAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WCRE FOR WHICH THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION'AWS OF CALIFORNIA.- THE PUCANT, M{U/ET HO IN CALL ADVANCE FOR ALL REQUIRED INSPEECTIONS AT 13MI/SBJAXB. COMPLETE DRAWING AT LOWER AREA RgVIDED`. // sl' X �,h Till. e /y-Pr D.H. 111 1/W� PLOT PUN ID,.w 1.BId.I Bade 't. 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE MPERTY. M. LOCATION OF SHOUSE SEWAGE DISPOSAL SYSTEM On PIWPOBEU 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ... .. :.. .. .i... .... .<. .....:... _ ... . .._ o ... ,. ... a.... ` .._. ... . .. .. ... .. .. n n ... v ..;.. .'_... a .. >...'... ..._. ... .. .. ._. ENT .0 J*VE,D p JAN _ g T ✓ .... SA�4.JGA IN GGUNTY - \i' ?U8 SIC ry�LTH SEI%II 'ES f _ .. ;. NLIRGNbiEF(fAL HGgLTH DIVfSIGN OBD rh .... -DEPARTMENT USE ONLY Appll..IFon A.a.pl./BY A .t/. Ma s G,.W knpeallan BY .le Pump Iropeaean BY V D.1. D..awSan Ironaat//b��n rB�Y-��[ 2 r/ II D.l. cammern.: ��1.`JN ,J o � rl✓U'i u/' M I Q I ACCOUNTING ONLY: ND/ FACE PE CODFf FEE INFO AMOUNT REMITTED CHEC /CABN I RECEIVED BY I DATE I PUNIITISLTIVICE REQUEST NUMBER INVOICE 0SO �'a�a8 (P� i 9l Pub.Health Serv.-Enviro.173(1197)