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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NDN•RuUNDARLE PERMIT EXPIRES 1 YEAR FRDM DATE ISSUED (complete M TT`Ilkflfl APPLICATION IR HERE BY MADE TO TIIE RAN JOADUIN COUNTY►OR A PERMIT TO CONRTFIUCT ANO/On INRTAIL THE WORK OFSCnIREO.TAMS APPLICATION IR MADE IN COMPLIANCE WITll SAN JOADUIN COUNTY DEVFLOPMFNT TFTIIf,CHAPTER B-'11115.,AND THE RTANNOARDR OF RAN JOAOI/1N COUNTY N1RLK:HEALTH SERVICES,ENVInONMEMAL 14FAITII bMRION. JON AfMFWRSA)n APNI X67 3QZ� E• tA,!)�N Ajr-y O IK CITY_iL �/�ti 1 n PARCEL SIZE/APR/ OWHF R'N NAME �t I/�.L� -Lzc'- � AOOIIERR ZD)',I Q. A I'G.QTG ak.'sjyEI CONTRACTOR �YL A5S C.LIGd-'C.S �"tL ADfMERR 11.�Q �j CryfH -5 tLICI P110NFI S> I�ZcGI RUR CONTRACTOR V L VNJ D t^Ll l l..`q AeOnf ee p•O-�e�c SI R-sC V USI_Llc►-7 7,6,1,o y d PHONE 11.07.3�y Z O r TYPE OF WELLJPUMP� NEW WELL C3 1 ❑ REPLACEMENT WELL MO"FT ONNO WELL• ( -3 ❑ OTHER ❑ INRTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSR-CONNECT nFPAIR ❑ VAPOR EXTRACTION WELL I El ❑RlwRtdr ILP, DFPTII PUMP RFT FT. FInRT WATER I FVfI O rt VI`E OF PUMPI RT--yI ❑ OUT-0E-SEnVICE WFII U OFORIIYRICAL WTI I-I_ u ROIL NORINO N IJ OF RT M IC T ION: INTENDED USE iTPE Of W CONETRI1CfION fPECIFICAIIIONO AA A ❑ INbIIRT MAI ❑OPEN NOTTOM DIA.OF WELL EXCAVATION UtiLti_ DIA.OF CONDUCTOR CARING O ❑ OOMFRTICMRIVATE ❑GRAVFI PACK/Rf2f TYPE OF CARING/STEFI/PVO. Pj L MA.OF WFII CARINA _ D ❑ PVNIICIMI/NICIPAL ❑DRIVEN OEl?ll OF"ROUT REAL -I 3 MECIFICATION R ❑ intunATION/AO 1:1 OTHER nMtIT RFAL MITT ALI FD BY C �J nnO1/T NRANO NAME F bI( MORTARING OMUT SEAL PUMPED: tAY•. No CONCIIfTE 1fDESTAL NV bRRLER:❑V•• ❑Ne S APMOX.OFP114 `-T LOCKING CHESTER"OX/STOVE F4Pf S RROPONED CONSTKIC T/ON/DMlUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HfgfRY CERTIFY THAT I HAVE PREPARED THIS AP POCATION AND THAT THE WORK Wkt.RE DONE IN ACCORDANCE WITH SAN JOAfNRN COUNTY ORDINANCES,STATE LAWS.AND RULER AND nEnIRATKINS OF TNF SAN JOAOUM COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CFMIFY THAT IN THE PEFKOIMIANCE OF THE WORK FOR WHICH T{SS PERMIT IR IRRUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'•COM►ENfATON LAWS Of CALKOMNA.- CONTRACTOR'S{OItlHO OR RUR CONTRACT"RIONATURE CERTIFIER 111E FOLLOWINO: 'I CERTIFY THAT M TIE PfAl ORMANCE OF T{1E WORK FOn Wl11CH THIS"IMATT IR MRUEO,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-8 COM"WSATION LAWS OF CAI IFORNIA.' THE APPLICANT MUST CALL 24"OURS IN ADVANCE FOR ALL REOIIMIM IRSF7CrIONfAAA'T 1111"1 4*0 54422. COMPLETE DMNANG AT IOMIER AREA PROVIDED. 2 Q Q Rlo..wd x� � _T111•_ R R I .Q-�.�� De.� // L D PLOT PIAN(Dr•w to Re•I.1 Rw.l• M 1, NAMES OF RTFIEFTR OR ROADS NEAREST TO OR POUNDING THE PIROPERTY. 1, LOCATION OF HOUSE RFWAOE DISPOSAL SYRTFM On PnOPOREO 2. OUTLINE OF Tiff F7gPERFY,ONVSNO DWFNSgNR AND NORTH DIRECTION, EXPANSION OF RFWARE DIBMRAL SYSTEMS. T. D/MENRIONFD OUTt1NF•AND LOCATION OF ALL MI TNM ANO PROPONED f. LOCATION OF WEULE WFIIMN RADIUS OF ONE I/IRNbrWn FIFTY r. STRUCTURES,I NCLUDINO COVERED AREAE SUCH AS PATIOS,DfEVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINNNO IEtOTERTY. 11 _ I L„� � •Nn �Z1 (7 6 6 cmn ao,a w..s•. sw[w rtD r'./o MC SITE MAP .:.....;..............................._ ...... �) DEPARTMENT USE ONLY L6.0 In•ewellwn Rr �iJ/!S d" `�/( 0." n.nP I—p-tt—NY 0.1. nw—.fl1..•Prllwn Rr / DN• cw mw 1. SLG�L.rl! lt1 C Gi e •G e�+��T t+ - S 4zd LL! L_ GcCti l! 7 litic^ _ fACCOVN11N0 ONLY: ALO/ MCI PE CODES FEE INFO AMOUNT REMITTED { C /CASH I RECEIVED BY DATE ►90NIi/fm"CE REQUEST NUMNER INVOICE 301gvA) (pCIO r(p je o/ -7 � D,.[. 4�.N1.CRI.., _Cn.J•n 177/1/�)1