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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV` ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388. 3D4 EAST WEBER AVENUE, STOCKTON. CA 95201388 (109) 4683420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TrlpRe$t$) APPLICATION IS HERE BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOKS DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT THU.CHAPTER 8-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PLIBLM HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. (/ JOBAODRE88IO-RFJAAPNI ati/s,�, (-o�w w.�/ akk, /Blvd CITE/, Jq?'/ k-/ DA PARCEL BIMAPNI IOL7-D (mo b OWNER'8 NAME/�/JM454(. W�f('E•1 �OAVllWIM ADDRE68021J-1(��t1n/Ey. �/� PHONED ) y CONTRACTOR rAV I ro5 I�J•/YI(G.i.E', '*R�.�. ADDRESS -p,D•�bx D2 Q LJCI PHONE E Zo]-9JS-KA'SD Sun CONTMCTOR 7 T.V1.ST'Fia. M.A�1.L AnDITFS �3b FfvtBti Rd WI artl'ryz Me PHONE 0610-313 STDd TYPE OF WELUPIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ meTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑N-0 R M' H.P. DEPTH PUMP 6ET_fT. FIRST WATER LEVEL O ❑YPE OF PUMP) ❑ OUT-orBERVICE WELL ❑ GEOPHYSICAL WELL l )(I BOIL BORING (IP-3 B ❑DESTRUCTION' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION CIA.OF CONDUCTOR CASINO n ❑ DOMESTICB`RIVATE ❑GRAVEI.PACK/BILE TYPE.OF CASIMISTEELAVC RIA.OF WELL CASINO O ❑ PIALICARINICIPAL 11 DRIVEN DEPTH OF GROW REAL SPECIFICATION B TTT❑qqq IRRIGATroNIAO ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME E UJI MONITORING GROUT BEAL PIMPED: ❑YHA [I NA CONCRETE PEOESTALBY DRILLER:❑Yr [IN. 5 APIAOX,DEPTH LOCKING CHESTER BOXMOVE RPE 3 PROPOSED CONBTRUCTIONImSLUM METHOD: MUD ROTARY AIR HOTARY AUGER CABLE OTHER I HEREBY CERTIFY T14AT I HAVE PREPMPD THIS APPLICATION AND THAT THE WORL WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED A(IFNT'S SIGNATURE CERTIFIES THE FOLLOWIM:-1 CERTIFY THAT m THE PERFORMANCE OF THE WORK FOR WHICH T141S PERMIT IS ISSUED,I SHALL NOT FMPOY PERSONS SUBJECT TO WORKMAN'I COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB;OMTRACTIM SIGNATURE CERTIFIEB THE FOEL WINO: -1 CEBUFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFO US r'1 APPLICANT MUST �A�LL�1S fb SIN ADVANCE FOR ALL MOUTHED INSPECTIONS AT LCOS)4454122. COMPLETE ORAWING AT LOWER AREA PROVIDES. DoT PLAN mP..Y m Mewl 1. NAMES OF ST 8 OR ROADS NEAREST TO OR BOUNDING THE PIOPRIY. 4. LOCATION OF HOUSE BEWARE DISPOSAL SYSTEM OR PROPOSED S. OIFPINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF$MADE DISPOSAL SYSTEM& 3. DIMFTIMNED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WRMN MON$OF ONE HUNDRED FIFTY P. STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,ORVEWAY6,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 5 muptta�hec{' i DEPARTMENT USE ONLY Apnlleann A-,1M O,w1 kowmmo,9 DN. Rmp ImproHlen BY DID. Owlnsllen LnnxHen BY D.4. lfa DLO4- 4 — v ACCOUNTING ONLY: MDI FACT PE COD" In INFO AMOUNT REMITTED CHECKMASH RECEIVED by DATE P TRERNCE REQUEST NUMBER INVOICE oan• ot3 Pub.Health Sam.-Enviro.173(3/96)