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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, "Il N.BAN dOAg1}!N- ,STOCKTON,CA 95201-388 i (209)488-3420 1; +L M NON•RFFUNDABtt PERMIT EXPIRES 1 YEAH FROM DATE ISSUED Mw*1Ah NL TI#Ussul I r APPLICATION 18 HIRE BY MADE TO THE SAN JOAQUIN COUNTY fOR A PERMIT TO CONSTRUCT ANOXIA INSTALL THE WORK DESCRIIIED.THIS APPLICATION 17 MADE W COMPLIANCE NAYH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THF SYANOAADA OF IRAN JOAC FIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OIVIGIoN. 13CLI4 JOBADDREssroA AP11 sPca LbR� cgt l 7y Ca2A rID CpEIAL 13L,VR Cr. `�T� -�I� C PARCEL AIZEIA�PH/R� OWNER'S NAIAET� A LD`T�PaNP.�O�oT Ee 4�43VnnknrmeyL AVE.t4epow piF7WI W zpI1pITE f 4 Z'rJ7 5Gc7 CONTRACTORVi WGLL��l_L44t+IFL ADDRESS FO.Gb%k f�I !, aV1YTT•1li `(,A134 i_-IZ oT pl{pNE.►7b?-��Z.D� SUS CONTRACYaft ADTMEA& LIC* P10NE TYPE OF WELIJPVAp- ❑NEW WELL ❑REPLACEMENT WELL ❑MowT'ORMVO WELL* ❑OTHER ❑INRTALI AT.N ❑WEI,L RVMEM REPAM ❑CAOSS-rONNECY REPAIR ❑VAPOR EKTRACTON,VELL YYYPE co,RVMp1 ❑N_❑n".1, H,P. Def-IM PUMP GET__"-'FT. FIRST WATER IEWL O ❑OUT•OF-AEAVICE WELL ❑GEOPHY&W.AL WELL P ❑ SOIL BORING g ®OESTRMT'oN:� 1v11A(RS �." j- {p{y, .�:Eaeuy" c'ro i..I-5u2F't�C MA►SIFCSTta^tlt 1 72�-MGVA . IYTLNDEP UAN TYPE or iwaL CONSTRUCTION EIec-CATIONS�y A ❑1NOUSTRIAL ❑OPEN BOTTOM O1A.OFWFLIFXCAVATION___-_b.2-S MA,OFt0.DUCTOR gSINO /� p ❑DOMESTICMMVATE ❑GRAVEL lACKISRE TYPE Of CASINq{BTEELIPV['iJ49 40 P\/4-- INA,OF WELL CASIN 7 X�� 7.IIX I�Alk ❑PUBIICAANNK:IPAL ❑OPSVEN DEPTH OF GROUT SEAL O—5 r SECIFICATION # ❑M MOATION/A(l Q OTHER GROUT SEAL INRTALLRO IV GmM AMNO NAME E ❑MONITOTYNO GROUT seA RLMAPEO:❑Yr ❑N. CONCRETE P'EDEHYAL SY DRILLER;❑VM ❑N. S AFPROK DEPTFI LOCKOM OHEBTER BOx/gTOVE PATE S, n M&M CONSTAUCTIONID16t UNG METHOD: MUD ROTARY ANI ROTAAY AUGER CABLE OTHER I Ng"CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDWINCES,STATE LAWS,AND RULES AND REGULATIONS OF THE GAN JOAQUIN COUNTY,NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFR:A THE FOLLOWING:'1 CERTIFY THAT W THE PtRF01MAANCe OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.i SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HNV46 OR AU6CONTWWCTTNG SIONATVRE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IA I&SVED,1 SHALL EMPLOY PEROONS SUBJECT TO WORKMAN'*COMFUSATION LAWS OF CALIFORNIA: THE APPUOANr MWT CALL L HOUI.R IN AOVANCd FOR ALL REOUKtFb INRI•F6 NS AT 426014KRa*YR.COMPLUS DRAWING AT LOWER AAEA PROVIOEO. r�LG�� 1✓. OAT BE4hq ;:Or V*W j)pktA-Lt-ir r 1^ /7 SISR.d X TNI. - -- GEQ I_CAS�... U.1. ZZ��i-b_. '(ZLe.H4¢Ll L..laAhj$onI KMT MN 0—Is GR.1.1 SA.IA 1.NAMES OF STFMA OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED t.OUTUNE OF THE PROPERTY,OIVNIO DIMENSIONS AND NORTH DIRECTION, EAFANSION OF SEWAGE DISPOSAL SYSTEMS. a.OIMENBIONED OUTLINES AND LOCATIOIN N OF ALL EXISTR AND PROFoRfo i.LOCATION OF WELLS WITHIN MOWS OF ONE HU"owo FIFTY FT, STRUCTUR E%INCLUDING CovemeO AREAS BION AS PATIOS,aUVEWA`PA,AND WAIAS, ON THE PROPERTY OR AOJOININO PROFEA Y. 144` t'1=.I.t•'I nR-ZI , - aUr�b Lmvit_ Via. ... 0.4 .. €. 1!Ir p :1 P�rTta =1.4 alis l to T V 14X ��' lbs• FP-YnlulvLE I• _ .J. N1 14XCo.oa3)%Its 1.Z:b�r}3 I; _ � 1.-74�'}-3.1`f,7LCo.cr:i3)z•1�,� ►.,��.. ��' 4R21i>.� HW V. .HS►- 1.44�I..T `1 t. .41 T:t>,;L 19'' DEIARTMENT USE ONLY Apoll.oli-A--I d Br i D.I. �.F' A+r Gloat 1"P Ow OR O.S. r"P INp.HIM BY bA.RUcd. IIwP.aden ev O.S. cRmm.nlr ACCOUNTING OMLYI AI9I FACR FE CODE& FEE IYFO AMOUNT REMITTED R®DYED RY DATE ►pMTI*DL 04 REGUEFT NLwlm WYOKE