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I q0 I U 5 ' P'PLICATION FOR WELL/PUMP PERM]& COUNTY PUBLIC HEALTH SEWCES 1 ENVIRONMENTAL ONMENTAL HEALTH DIVISION E ST WEBER AVENUE, STOCKTON, CA 95202 37 (209)468-3420 j—�� 'Y1,c'r p 1'�NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED —1 O (Complete In TEIpRentEl APPLICATION 18 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMEENNT TITLES.CHAPTER 9-1115.3 AND THE BTANDARDB OF BAN JOAQUIN COUNTY �PUBLIICC HEALTH .tSERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODflE88/OR-AFRI/ I�//(/J///✓r^—,V. ytt ,!//� � CITY S/ T/C/��✓Y PARCEL SIZVAPN# e2oS 7 /� OWNER'S NAME '///](/r� 1_,./.N� . ,�/ Z 9A .8 3r, ADDRESS CONTRACTOR ]/GTI'Fl!11��,.��Y�J11�� J ' / ADDRE88 UC/ PHONE IF SUB COMPACTOR 5t+- JG� �/y- /y ADDRESS 6r UCR�PHONE,5A MAIL TYPE OF WELL/PUMP: ❑ NFWWELL ❑ REPLACEMENT WELL MONNORINO WELL R ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS{ONNECT REPAIR ❑ VAPOR EXTRACTION WELL S ✓ ❑New❑R.p* N.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O (TYPE OF PUMP) 11�� OUT-OF-SERVICE WELL ❑ OEOVBICAL WELL F ❑ BOIL BORING B N7DEBTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ WMESPCMRVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEE F441 !) DIA.OF WELL CASINO O ❑ PUSUCIMUNICOPAL ❑DmVEN DEPTH OF GROW DEAL A.,L. .4 SPECIFICATION �-y� R ❑ IRRIGATIONlAO OTHER GROW DEAL INSTALLED BY &0 11- GROW BRAND NAME ,% G&Y7E1 E fWMONITORIN rFHv('� / GROW SEALPUMPEO: ❑Y. ❑N. CONCRETEPEDESTALBVORILLER❑Y. [IN. S APPROX.DEPTH LOCKING LOCKING CHESTER BOX/STOVE POPE b PROPOSED CONSTRUQTIOI mmau ND METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE DAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1 MAU NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COHTRACTOR'B HIRING OR OUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN PIE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS BUWECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 31 HO N ADVANCE FOR ALL REGUISEG INSPECTIONS AT 11101111 4" 2S. COMPLETE DRAWING AT LOWER AREA PROVIDED. SIO�X TSI. 57,h�— 1>' 7rYZ-06:dS7' 00. PLOT MN IDLY/to 84.1.1 9..1. T Re*`J / 1. NAMES F STREETS OR 9p DS NEAREST TO OR BOUNDING THE PROPERTY. - t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PIOMBED Z. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWARE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLIES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF MUD WITHIN RADIUS OF ONE HUNDRED FIFTY Ft. STRUCTUnEB,INCLUDING COVERED AREAS SUCH AS PAPOG,DRIVEWAYS,AND WALKS. ON THE PROPERFY On ADJOINING PROPERTY. Sri/ H z� �v r GAJ/e1.T 02- (gets 13 . C . dPING I� I