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APPLICATION FOR WELLIPUMP PERMIT <br /> L SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> p b L,✓ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (C{mplet{In TFIpIketEl <br /> APPLICATION IS HERE BY MADE TO THE SAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT ANDPOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPtIANCE WUH SAN <br /> "AMIN COUNTYDEVELORAEM TRLL.CHAPTER 1116.5 AND THE STANDAR a OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> r4110JOB ADDRESSMR APN/I/♦� CITY A19) a...s PARCEL 91ZEAPNI <br /> OWNER'S NAME lam' ADOIIEBB w� R10NE{ <br /> r CONTRACTOR a... 2::;1 c ADDRESSqq7ji�z. L2,Q�LK:e.37. Std RIONES <br /> AVB CONTRACTOR ADDRESS me RIONEI <br /> TYPE OF WELLMUMP; ❑ HEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> i ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CM98-CONNEECCT`REPAIR ❑ VAPOR EXTRACTION WELLI J <br /> 1:1N. V9 RePNT H.P. � DEPTH RUMP BET'�C• FT. RRBT WATER LEVEL Asa V O <br /> (TYPE OF RIM% <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> El INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> DOME9TICLIIIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOtWEELTFVC VIA.OF WELL CASINO O <br /> LJ PUBUUMUNICIPAL ❑MWN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME E <br /> _ ❑ MONITORING ^ GROUT 6EAL PUMPED: ❑Y- [IN. CONCRETE PEDESTAL SY DRILLER:❑Yr ❑Ne S <br /> APPROX.DEPTH 49L / ' LOCKING CHEWFn BOKISTOVE RPE S <br /> PROPOSED CON{TRUCTONRDRIlIlNO METHOD: MUD ROTARY AIR POTARY AUGER CABLE OTHER <br /> r I HEREBY CERTIFY THAT I IIAVE PREPARED THIS RRICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN"AMIN COUNTY. HOME OWNER OR UCENGEO AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTMCTOR'0 HIRING OR SUN CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN T 1 WCNCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPEI ATION LAW{OF <br /> CAUFOR HE PUCANT MUST Z4 ILC I{IN ADVANCE FOR ALL REQUIRED IIJL&�PSVTONS AT IZU{I 46114S29. COMPLETE DRAWING AT LOWER AREA RIOVIDED. <br /> elaeed X T10. Deb <br /> PLOT RAN 101—b Sete)Beeb 'ie <br /> 1. NAMED OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOURS SEWAGE DISPOSAL SYSTEM On PMROSE0 <br /> Z. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWADE DlBP06AL 9YOTEM9. <br /> J. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN MMUS OF ONE HUNDRED FIFTY R. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> NOV5-0 <br /> T. DEPARTMENT U{E ONLY <br />