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r 41 APPLICATION FOR WELL/PUMP PERMIT <\� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNUABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CempletF IR TrlpReattl AMICATON 19 HERE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOOR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER B.1115.3 AND THE 9 ANDAPDB OF BAN JOAQUIN COUNTY POB C/ ALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. / JOB AODW SSMM APR 41f1 1� �(��(E,//(LE Z7I✓I �'/�'I( CITY G L PARCEL SIZEJAPN&/ OWNER'S NAME C h//4aN' L,yJ C{L/ LJ ADORER . CJ ./- ,4'T a / PHONE f T q CONTRACTOR � /�1 rl' D S ADDRESS/I[/dflZPk^(- (NONE 4�57? f SUB CONTRACTOR ADOPE88 UCI RHONE I TYPE Of WELLPVMP11-91JIEW WELL ❑ REPLACEMENT WELL ❑ MOND ONNO WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROOB ONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ✓ ❑N.n❑RyYr HP. OM1H PUMP SET FT. FIRST WATER LEVEL ODe DYPE OF RIMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL F ❑ BOIL BORING S ❑ DESTRUCTION: V` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A i/ ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �� DIA.OF CONDUCTOR CASINO O ODPMESTrVATE VEL PACKIBIZF TYPE OF CASIN018TEELJINC pw DIA.OF WELL CASINO e� 11PUSL1CaMUNICIPAI ElDRIVEN DEPTH OF GROUT SEAL ZO E:/n' SPECIFICATION R ❑ IRROATIONIAO ❑OTHER GROUT SEAL INSTALLED BY <t '�( C OFUVT BRAND NAME � E ❑ MONITORING GROUTREALPUMPFO:XYr [IN. CONCRETE PEDESTALS DRILLER:❑Yr b S APPIOX,DEPTH ,7201 LOCKING CHESTER BOXISTOVE RPE ! PROPOSED CONGTAUCTIONTMOMING METHOD: MUD ROTARV�AIR ROTARY AUGER CABLE OTHER /� 1 HERESY CERTIFY THAT I HAW PREPARED THIS APR1CATpN AND THAT THE WORK WILL BE DONE TRH ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO v, REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTHIEB THE FOLLOWBO:'I CERTIFY THAT IN THE PERORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SURACT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUSLONTMCTINO SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SMALL EMPLOY PERSONS SUBJECT TO WOMMMAN'8 COMPENSATION LAWS OF CALIFORNIA.'I TIIE APFVCANT MUST GALL i./OItV IM ADVANCE fOR ALL RFOIARED INlPFCT10Nt AT IZOSI AttSIiS. COMPETE DRAWING AT TOWER AREA PIONDED. /A Y SID,wx V LC. My-1, y Hne tie le.- D.I. ROT RAR SO—le BaN.I SeH. fe _ 1. NAMES OF STREETS OR WAGS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE MWAGE DISPOSAL SYSTEM OR PDPOSEO 2, OUTLINE OF THE PROPERTY.GIVNNG DIMENSIONS AND FORTH DIRECTION. EXPANSON OF SEWAGE DIMOSAL SYSTEMS. ]. DIMENSIONED OVTUMI'S AND LOCATION OF ALL EXISTING AND PROPOSED F. LOCATION Of YELL!WITNIN MdUS OF ONE HUHOPTD FIFTY R. STRUCTURES,p LUOIFM)COVERED AREAS SUCH AS PATO$.ORVEWAY9,AND WALXB. ON THE POPERTY OR ADJOINING RROPERry. IN a 54 C �jL�s v ioV PAYMENT 0 MAY ' 1 1998 PSAN JOA �NWNTAL TH NEA"SEH I ION DEPARTMENT USE ONLY !T, AP9rHen AP. .1 OF " '^tGf�G2�-c D.I. ` �7 ` Mr •) I ro.ul in.ernen er DHS PUme In.vrnen er D.1. nrU�sD.n Iw.rLlen av D.1. ms,l. o IA' - ILI Qt - hu � IAJ' ACCOUNTING ONLY; AIDS FACT PE CODES FEE INFO AMOUNT RETMTTED SMASH RECEIVED SY DATE PNMITIBM"CE REQUEST NUM RM INVOICE 5'17V Pub HeaRR SON.-EnVlro.173(1197)