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ji APPLICATION FOR WELLIPUMP PERMIT C --..-JOAQUIN COUNTY PUBLIC HEALTH SERVICESw,� Wlt ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95(209) 468-3420 . moo I� r NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �{ (Complete in TFiplic{tel APPLICATION I8 HERE BY MADE TO THE SAN J OUIII CO INTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 16 MADE IN COMPJANCE ATTH SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CMA ER 8--^11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION./_ ��11,�,, JOB ADDRESSIOR A/PyNII " I I O - OL� CITY c /' (- PARCEL SIZE/API, 3� V, 4(/7jiq OWNER'8 HAVE_/n g ADDRE68 .�1 �(� (0 0 - g5c)= PHONE �Y� �[� COMPACTOR Od D1- � ,Iy.�L,), lI ( �IF'� I I � �Q ADDRESS 1"�1C� (13,3 Vf e9 3. �/ y� ��LICO_ ' 430 PHONE 0 95-qJ-Q SUBCONTRACTOR J"E-I( STI,( �(�Y 1 ]� I L (,[ ADDRESS 1F� �J/I k 1 c'y 1 L,./I `- &O PHONE �737Gi TYPE OF WELLJPIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL ISY/STEM REPAIR ElCROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION �W U 0 yf l J ❑N.Xb Ir H.P. I ,T� DEPTH PUMP SET��FT. FIRST WATER LEVEL 04.�J r T O RYPE OF RIMPI & C1 OUT-0F-SERVICE WELL 1:1GEOPHYSICAL WELL I ❑ SOIL BORING g l:J OEBTRUCTION: %1(� o n lr� / A V%A I I I LULc 1 1 Q INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION/ A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PNVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEELN C DIA.OF WELL CASING O ❑ PUBUCIMUNICIPAL 1:1 DRIVEN DEPTH OF GROW SEAL SPECIFICATIONR 11IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME iX E ❑ MONITORING GROUT SEAL PUMPED: ❑Y. ❑No CONCRETE PEDESTAL BY DRILLER: Y. [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE RiEPARED THIS APRICATION AND THAT THF KOgC WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:1 CERTIFY THAT IN THE PERFORMANCE OF THE MW FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CON'TRACTOR'S HIRING OR BUBLONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' ARIJCANT MVR CALL 24 HOU({IM ADVANCE FOR ALL REQUIRED INSPECTIONS AT 110111148,11,Z41M COMPLETE DRAWING AT LOWER AREA PROVIDED. Tlna C� C� (f_ F D.I. ROT RAN Qr. to So.i.l S..I. 'to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUTLINE OF THE PFIOPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMS. �- 3. DIMENSIONED OUTUNF8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF W 118 WITHIN RADIUS OF ONE HUNDRED FIFTY FT. Qk STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE RtOPERTY OR ADJOINING PROPERTY. X31 l9� Ui3c P w f 1 G�� d Y� ov w a Ae r(ti SILK eve-erew e 0-L f,0,aj- e1L_e/) loo' 1n 3�2�06 �nmpn a icy e) �v b of aA J R vT dP �VY�S 1 ,d COPY 13 III )T . �, 2p0� 53/162- f nA� - am U-&M Cc �? ,j�/ v t%0Gooti' I c (.0-t'-LP -0 6," 4IC Jk K- �pRPut OEO sS�N Y��tCLh k2e v. . e aAq VX CRd( t� SPNLCNEP`NEa1N P�.NMPcabp' 691 ! ! c �J C -9 0-D" IfT EONLY �_ 5' d6> LUI /.�C.Q�JV✓IG.M-.jam a i A.Pll.11en Ae.grtM.T •� G.I. -/ Y' 'C� ArY z 1 5 E,,/ImPL.O.R By �1 f � 0 .(L;` D.1. D.t,.Jlon Im,.ton 8, L�/ Comm. ts: 02- (e til sI I'c c c u L utQ R c(c.F S4Oo2 6 12o0-z2k� S(z002 ?,f70 ( /1 &'!Ll ACCOUNTING ONLY: AID, \\ FACS PE CODES FEE INFO AMOUNT REMITTED CHECKIICASN I RECEIVED BY DATE . ITISEAVICE REQUEST NUMBER INVOICE ,1 yl�JA Jt: J h S-0— 672- O �i