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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AVENUE,STOCKTON, CA 95201388 (209) 468.3420 NON REFUNDABLf PERMIT EXPIRES_I YEAR FROM DATE ISSUED ICBmpI6t6 in TrIPIf66Tel AYPUC ATI IN IB HEREBY MADE TO 714E SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INET ALL THE WORN DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH BAF JOAQUIN COUNTY DEVELOPMENT TITLE, •�lCHAPTER �9.111 r15.3 AND /THE STANDARDS OF SAN JOAQUIN COUNTY PUBLICO HEALTH SERVICES,ENVIRONMENTAL HEALTH Or ASION.7 JOB ADDRESSOR APNI. /l 9r�/I� J /"""J TC%_ ql.7 CITY Irk ` -' "V`vY{_,E /'� PARCEL BQE/AP,�f • /�� OWNER'S NAME��t tN A(.l Y-l'�t MSE Q'__."1 ADDRE68 /5 U/ 4/` ^`g1�1C C / P}IDNE f CONTRACTOR �~r' WIC"L�.- ADDRESS r-LJ 4' ��ryl'1{,�1 LIC/ �I PHONEf 7 BUB CDNTRACTOR ,,,.�/ ADDRESS LICE PHONE/ TYPE OF WELLRIMP; L1;T NEW WELL ❑REPLACEMENT WELL ❑ MoNRaRINO VELLI ❑OTHER_ ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROBS•CONNECT REPAIR ❑VAPOR EXrRACT10N WELL I ✓ 'TLxI`ts;�, d N.«❑4.p.1r H.P. DEPTH PUMP BETI-c-FT. FIRST WATER LEVEL 0 RYPE OF PUMP ❑oVfOFSERVICE WELL ❑GEOPHYSICAL WELL I ❑ BOY somma 8 ❑DESTRUCTION. INTENDED USE TYR0 CONSTRUCTION SPECIRCATIONB n K A ' f❑�TNDUSTRIAL f❑�FO�PEN BOTTOM DIA,OF WELL EXCAVATION L 1/ fir OIA,Of CONDUCTOR CA.11 U DOMESTIC/PW VATE .9ZRAVEL PACK/SITE -( TYPE OF CAMNWFTEEUPVC �SjfyC c A.OF WELL CASINO /y-� � D �❑�{{PVBUCAAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 5/�11, _ SPECIFICATION t�Y,Jt�t A I C�IllATION/AD ❑OTHER GFIOUT SEAL INSTALLED �BTY�T1-�.1 Y/llt. GROVT BRAND NAME E�F'C�/C fjAU E ❑MONIT OMNO GROUT SEAL PUMPED: GSY- U Ne CONCRETE PEDESTAL BY DRIUFR(1Y- ❑Na 3 { A►PROX.DEPTH LOCKING CHESTER BOX/STOVE PPE. PIOPO►ED CONSTRIICTIONIDAIWNO METHOD: MUD ROTARY AIR nOTARY AUGER_ CABLE OTHER e� -4- THE BY 4-1HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AN REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LE-ENSED AGENT'S SIGNATURE CERTIFIES TH!FOLLOWING:'1 CEFRIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHIG THIS PERMIT 16 ISSUED,I @HALL NOT EMPLOY PERSONS SUBJECT TO VIORKAAAN-6 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BV"ONTRACTING SIGNATURE CERrIFIE THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE M,M FOR WHICH THIS PERMIT 18 I66VfD,I BHALL EMPLOY PERSONS SUBJECT TO WOR"AAN'S COMPENSATION LAWS O CAUFDRNIA." THE APPLICANT @{EyT/C/A1�1 K/OURS IN1ADVANCE FOR ALL IIE000IED MSEC NS AT/I/,O)4/6�S/3 227. COMPIUETIEJDRAWING AT LOWER AREA/F/f4OVIDED. Blond X__F 1 11f ! �l _TItH `-CN'(�. L� ` DEt. `� IF PLOT PLAN IDA 1.B.W.I S-1. 1. NAMES OF STREETS OR PIOADS NEAREST TO OR BOVN04NO THE P OPENT', 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENBION8 AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ] DIMENMNED OUTLINFS AND LOCATION Of AL1 EXISTING AND PROPOBEO S. LOCATION OF WELLS WII NN RADIUS OF ONE HUNDRED Flmi Ei. STPUCTUSES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALA9. ON THE PROPERTY OR ADJOINING PROPERTY, . .'. ..... .. .t.. .... I .. .. t. .. ....... 3] ... ... .:. .. . . >. i .. .> ti AR ... _ ,A 1 1 J�IJlJ h.� l ii f1 ${I SISI -ON 4EIj ..... ... .. '.... ..`. . .' . . NVI . .I'�ItAlTy.f]IVI --� 7.vot : . : ... .......... . . .. ti : ...: . i. :.., Jr .. zfnL DEPARTMENT USE ONLY F ADPII..tl.n An. [P By 0.1. G.Otn Irwpectbn BY, _ D b 5.117 Puny I'pwtlo BY D.1. V OstrAcllAAn Ir'.P.�tlon By bt. D`f&,, 4" JZ& o Q 2 0 +-,s3 uu.( e. IPvf Cl.S' .-S Cade S ACA OUNTINO ONLY: AIDI FACT �PIE CODES FEE INFO AMOUNT REOAITTED CHEC ASH RECOVER BY DATE P£TRMITTBFRVICE R..L—%S7 NUM66R INVOICE Ib ( Sof)D �-a •7 1 DIS o 4S7v