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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complus In Triplk$tt) APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DEBCRIREO.THIS APPLICATION 18 MADE IN COMPLIANCE WR11 SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 1B•1 1`16.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC ,1{I HEALTH SERVICES.ENVIRONMENTAL HEALTH DMQ810N. 1 JOB AOORE88/OR AP1NI - ] W I 1-1 --�[,_J,\( g,O� CITY I,CA I �IP�,A/RCJEL 81ZF/ArWf I I- 0� 1 LS rq. OWNER'S NAME \ J n✓ i�f V\cA, 1^ ADDRESS III "��/ 1&)30� '-'MJF•J 6 PHONE f (� N A7 7 7 7 COMPACTOR C I�� I�Y 1� AWRE88 �F VI 1 - 1"�' �C/ 2-r..G�y7 � ') y`�[, SUB CONTRACTOR OW 4 I ADORESSmL40 1 UCIH_M14AE l� 1 TYPE OF WELL/PVMP; ❑ NFW WELL ❑ REPLACEMENT WELL ❑ MONFTOPUNO WELL/ ❑ OTHER N ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ElCnOSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑Repei, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PVMPI p �-{I�o 6�I` ` ��y��- L/�' �pU/ ,❑ OUT-OF-SERVICE WELL ❑ 0FOPIYBICAL WELL 1 SOIL BORING e I�- �. �// S 111 DESTRUCTION: LM+✓� -II '.�a�- (BUY 1 y qj(/ INTENDED USE TYPE OFF WELL CONSTRUCTION SPECIFICATIONS ` .-{,__ Q, A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION LS7,, Iy V 1 VlC ' DIA.OF CONDUCTOR CASINO' `� D ❑ DOMESTICWRIVATE ❑GRAVEL PACK/81ZE TYPE OF CASINO/BN /PTEELVC A DIA.OF WELL CASINO y 1 D ❑ PUBLIC/MUNICIPAL -DRIVEN p � DEPTH OF GROUT SEAL SMCIFICATION IN R t❑ IRI RGATIO/N[ L7AO � 0THER C\Uq L/y/a�. -ROUT SEAL INSTALLED BBY_y ; GROUT BRAND NAME E Py, i`�! q Gi eotecj,. v vI GROUT SEAL PIMPED:`{ Ye. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y• e S APPROX.DEPTH LOCKING CHESTER$Ox/BTOVE PPEN S PROPOSED CONSTRUCTIONIDPoLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REOULATION9 OF THE SAN JOAOUtN COUNTY. HOME OWNER OR LICENSED AOENT'9 SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERKORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED.1 814ALL HOT EMPLOY PER90NO SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'9 HIRING OR SUB-CONTRACTMO SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PER MIT IS ISSUED.181/ALL EMPLOY PERSONS SU9JECT TO WORKMAN'S COMPERSATION LAWS OF CAUFORMA.' T APPLICANT MUST C LL 24 HOURS IN ADVANCE FOR ALL REQUMED INSPECTION AT(20011�44*0-TI422. COMPLETE DRAWING AT LOWER AREA PROVIDED. 91pned x Title C/\/ T D.1. I /�V O PLOT PLAN"-to Sc*Iel So-I. Io 1. NAMES Of STREET$OR SOROS NF T TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PIIOPOSED 2. OUTLINE OFT"[R'ROPEFFFI 01VING ENMONS AND NORTH DInECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTMO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIO$,DRIVEWAYS,AND WALX9. ON THE PROPERTY OR ADJOINING PROPERTY. T nnr,�le 944: ;. PP wEp L-0 h d SAN`O 0A H S Rv CE S\ON oS� Z+ P�B� EN�g-HEPoN ENv\BONN fir,r taw I L4 ; LT P�$a �M�P Gcl S�o �i`�c,(� �. 120�►�- IQ�. . , DEPARTMENT USE ONLY Appll-0-A-mid By - 'u Date Arm L/ (1-A I-peotlo� - �2 o I-P-0 n Sy O.t. Ile.ln�ellen Impeelbn BY D.I. C.-".: 'JCL A-P 4.-4 CrZ WO-•L�l ��z�,--��1 - iU� •.,_�.. �- ACCOUNTING ONLY: AID/ FAC/ PE CODES FEE INTO AMOUNT RFMRTTED CHEC ASH RECEIVED■Y DATE, PERMITISERVICE REQUEST NUMBER INVOICE