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it 3{Y APPLICATION FOR WELL/PUMP PERMIT! SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 i ROM-AEFUNDA$LE PERMIT OMBES 1 YEAR FROIA DATE ISSUED {CBRIpM[f In TrtpAmle) !F APPLICATION IS HERE 8Y MADE TO THE CAN JOAOUN COUNTY FOR A PEWMR TO CONSTRUCT ANDI'OR INSTALL TME WORX DESCRIBED.TFRS APPLICATION 18 MADE N COMFUANCE WRIT SAN i JOAOLIIN COUHTY OEVELOPIAENT TrnL CHAPTER 9-1115.3 AND THE BTANOMLOB OF CAN JOAOUIII COUNTY PUBLIC HEALTH BERIACES.ENVIRONMENTAL HEALTH DNI810N. z Iu I7f] 1 CITY PARCEL SIMA"M .. JOS AOOM9w0R A"o—BaMR111i CL{ C� 1Q1 ADDREBI P.O. $M 248 PHONE•$38-4100 i OWNER'S NAME. �-7 CONTRACTOR V & WADDPIEElcillimfg15 ct. rap Vista:*720904 PHONE�E 374-2815 llix ADDRESS i L)Cr PHONE r SUB CONTAACToR ,F TYPE OF MP• ❑ NEW WELL ❑ REPI.AcvAENT WELL FR MolatTOFatfa wEm r I E}{3y OTHER ❑ INBTAU.ATION El WELL SYSTEM REPAIR ❑ CROSB-CONNECT REPAIR VAFOR EXTRACTION WELL r 2 Naw❑Rw w H.P. DEPTH PUMP SET FT. It FRIST WATER LEVEL O ❑ iTYPE OF PUMM Cl OUT-Of-SERVICE WELL ❑ OEOPHYWCAL WELL r ❑ 804 Bompm a ❑OESfRI -froN• A INTE71DE6 USE TYPE OF WEL CONlTRUCTtOM i9EGFICAT1ONJt �� ❑ WOUSTRIAL ©OPEN BOTTOM CIA.OF WEU.EXCAVATION 6' DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ®GRAVEL PACKMa42g TYPE OF CAWMfflTEELIPHC 13rCIA.OF WELL CAMNO T, 1 D ❑ pUBUCMIROCIPAI ❑ORtVEIf DEPTH OF GROUT SEAL O-3O I .} SPECIFICATION n ❑ MOATIOHIAG ❑OTHER GROUT SEAL INSTALLED BY r(4X niP— OROUT BRAND NAMErMt CSTEnt E MONITORING GRDUT REAL PUMPED: 0 Y. ❑N• E CONCRETE PEDESTAL BY OWLLM❑Yw IJN• 5 APPROX.DEPTH LOK:RNO CHESTER BO XlfrovE APIE S PItOFOSUf CONSTRVCTIOIUDRILIIRO AIETNOW. MUD ROTARY AIR ROTARY AUGER X CABLE OTHER I HMBV CERTIFY THAT I IfAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REOULATIONS OF THE SAN JOACUIN COUNTY. HONE OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE PO.LLOWINGe h CERTIFY THAT N THE PMORIMANCZ OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL NOT VAPLOY PO No BUBJECY TO WORIDMAN•l COMPET$AT10N LAWS OF CAURDWRA.' CONTRACTOR'S MIOM OR SUS•CONTRACTINO MONATURE CpFffWWf THE FOLLOWING: '1 CERTIFY 114ATM AFQRMANCE OF THE WORK FOR WHICH TMl PERMIT M ISSUED,i MALL E1WPL.OY PERSONS MMACT TO WORTGMAW*COME HATWN LAW$OF CALIFORMA.- A Y CKMR ALL g1All®OIfPECTIpNf AT 12"1 4tl-W1. COMPLETE DRAWING AT COWER AREA PRO IED. S1an.d X � TM•�� D•t• Y PLOT FLAN Mvr to%041 Seal• 'Is Ij i !. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED t. NAMES OF STPEETS OR ROADS NEAREST 7q OR BDUIJOMO THE PROPERTY. 2. OUTUNE OF THE PROPERTY.OWING DIMENSIONS AND NORTH DNIECTION. EXPANSION OF SEWAGE pVVITI"RA SYSTEM. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EIIISTNG AND FROPOno � S. N THE ON OF WELLS ADJON RADIUS OF ONE TUUIIDREb FIFTY FT. STMICTIRES.NCLUMJG COVEr1E0 AREAS SUCH AS PATIOS,ONVEWAYS.AND WALKS. ON THE PRDPETTTY OR ADJOMn'KI PROPERTY. - - - :-�f _ - .. .. ., ' c�t�d 3/31/99 m E . . . .... ........ .......................... ............ it DEFAMMUrT USE ONLY 14 I! Aypkatlan A•a od B► 'F Date Z hr Grain Imp•.0on By D.t. 3a Pl .N... 'Im BY Date Oe.lnr.tl.n Inep"ion Br ON t Cm mew.: iE ACCOUNTING ONLY' AIOr FACT ,C PE CODER FM IpNFO AMOUNT RFIYf"ED CH£CIIrICASH RECEIVED BY DATE f! PURMITNEUVIC£REGUFAT NUMBER INVOICE QI r loo I� avb Health Serv.-6fr*D- 173(11" dV