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�/v APPLICATIO FOR WE PUMP PERMIT WELL SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 i10N•REFUNDABLE FERNUT EXPIRES 1 YEAR FROM DATE ISSUED / (CemplSb IN TEbBsaltl APPLICATION IS HIPif BY MADE TO 1HE BAN JOAOVSU COUNTY FOR A PEMV 7 TO CONSTTTUCT AN010" INSTALL THE MMPI( OE GCIOBED. THIS AFT PLAT ION I$ MADE IN COMPLIANCE WTlll BAN JOAOUIN COUNTY DEVELOPMENT TALI~ CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC IIEALTH NEFYICEN, ENVIRONMENTAL HEALTH FMVISION. JON AOOR£SWR APNI: JG,]'�L7:�-iD• C(TYi /J .. PAIICG{ iZfflJAAP, - / (4x7 OYINIF A'1 NAME±�/�iiJ�i`C /'c'/��'i Ku[_i/cf iL' .,----• ADORERS ��ii /[�J--. /h-. c:yi S71PN . COMPACTOR A000L' i '�Gic%..ZLY /-�u/�lr AOOIEBt!_Q, ' ' J�CXi[U_ A' iyl :,,V (cdPyJ />.S n.: �UCI '>w,>,'>c.zO F'NONEt G ; [_. PUN CONTRACTOR IrJO�D ✓ - %L�i/✓ - c1 ANS ADDRFI LUCFJi_f%PZ C,J PHONE F4rezaLiG ! %3 •TYYp OFyvELL1PUMR ® NEW WELL ❑ REPLACEMEM Wnl- ❑ MONSTONNO WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CAOSS-CONNECT REPAIR ❑ VAPOR EXTMAC TIOIJ WELL F J ❑ New❑Reek H.P, DEPTH PLUMP SET /T. FIRST WATER LEVEL O 0 YPE OF PUMP) ❑ OUT-0F•tE MICE WTIi ❑ OEOPHYSIC AL In/Fll � ❑ ROlL SONta6 R ❑ DESTRUCTION: . INTPI ED USE Tyft OF WDA CONSTRUC OM IPECIFICATIONS A INOUBTNAL ❑ Opt" BOTTOM ENA. OF WELL EXCAVATION tJ� - LMA. OF CONOUCTORCASTNO 4 a ❑ OOMESTTCIPRIVATE to GRAVEL PACKJMZE TYPE IIF CA1jINO/6TEE1JPVC_ ra'-.C.L _ _ MA. OF WELL CARING /[. " O ❑tmmm DEPTH OF OROVT SEAL E301L�4 SPECIFICATION AND Eftt. •�.T flog A �p❑►.�PUSLICMWOUPAL 49 111WOATIORtA0 ❑OTHER GROUT SEAL RMTALl" BA�Y �LE�IIi _ OPOtT BRAND NAME � E ❑ MONITORING 01401,17 SEAL PUMPEO: Iy Yr CIN- IU�� CCNCRVE PEDESTAL NY ONL1ETl ❑ YP. ON, S V Illy e. ADf1Wx. DEPTH LOCxMO CHESTER BOXMIOVE PIPE S PROPOSED CONSTRUCTIONI MLLOO METHOD: MUD FOTARYy�_ AIR FIOTARY AUGER CABLE OTHER 1 HEVENY CERTIFY THAT I HAVE PREPARED THIS AVIVWCATTON AND THAT T11E WOTK WILL RE DONE IN ACCORDANCE WITH SAW JOAOUM COLINTY ORDINANCES, STATE LAWS, AND ABLE$ AMO MOULATIONN OF THE SAN JOAOUIN COUNTY. HOME OYYNER OR UCENSED AGENT'S WONATVRE CERTIFIES THE FOLLOWSTG: '1 CERTIFY THAT IN THE PEKORPANCE OF THE WON( FOR VALICH TISK KFOM I Il 18"0. 1 BIIALL NOT EMPLOY PEiWONN NUNJFCT TO WORWAAN'S COMPINSATTON LAWS OF CALIFOR IA.' CONTRACTOR'S H$AINO OR SUB-CONTMCTING SIGNATURE CERTIFIES THE FOLL01MNO, ' I CERTIFY THAT IN THE PERFORMANCE OF THE WON( FOR WHICH THIS PERMIT IS ISSUED, 1 ONALL EMPLOY PERSONS SUBJECT TO WOMWAN'S COMPENSATION LAWS OF CAUFDPMA.' THE APFEMANT MUST CALL 24 SOURS IN ADVAMCI FOR ALL REOLARSD INSPIEC"ONS AT 1"01 440 -*423. COMPUIE DAAWINO AT LOWER AREA PROVK)EO. rPir rLa d%a�1CL�J5 _nu. Ditto ,�Ji/ __,d � PLOT PLAN 0— 1. Sow.l F-1- I 1. NAMES OF /TAFFY/ OR ROADS NEAREST TO OR NOVTTD000 TTTE PPOfER1-Y. t- LOCATION OF HOUSE SFWAOE DISPOSAL IY1rf I!M OR Pn.MRED 2. OUTLINE OF TIT PROPERTY, *TANG DIMENSIONS AND NORTH DAECTION. EXPANSION OF 9fWAO[ DISPOSAL SYSTEMS. S. DIMENSIONED OVTUWD AND LOCATION OF ALL EXIWTSFO AND PROPOSED I_ LOCATION Of WELL$ W"l-IM RADIUS Of ONE H UNOMD FIFTY FT. STRUCTURES• 1NCLVODUO COVERED AREAS NUC" AS PATIOS, DRIVEWAYS, AND WALLS. ON IIHE PROPERTY OR ADJOINTNG PROPERTY. . r. • 1 -1elli : t. . • .. .. • • ...;. . ..1.. ........... ; .... .. : 'i i t i S...... .... ...... . .Ik..... �... A"Ne.Nw, Awwl-d I Gree I.wfs.Il.n of_ DeNnt.tt-n I�P�1nen ACCOUNTING OtRY: I AIDF WAF DTPAATMFNT kill ONtT owe D.I. F1.n0 InNp-etbn BlY ON•�•��(/--(�J��1 GJ � �U>fERraa.t rRRLAJiIT/. YI�F�.':��s1F.Y�t'...Se.K:'tJi� U/ CF�LLL/PTI r�M'1/06UP FACF A 051.a11VAeD ,o 111 COVES FEE INFO AMOUNT AENETTED CHECK/ RAH RECOVEO NY DATE RmaTAIVTVHCE REOVEST NUMBIR q JULT C O0 7 0 c3? '..'1f !ct L 5 th rrec INvaee