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• APPLICATION FOR WELLIPUMP PERMIT•SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 3K 3N EAST WEBER AVENUE, STOCKTON. CA gsnj 98B (109I 469.3410 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED FILE COPY APPLICATION 18 HERE BY MADE TO THE SARI JOAQUN COUNTI'FOq A PERMIT TO CONmpfetv STROCTIgNDTORINSTALL THE WORK DESCRIBED.THIS APPLICATION I8 MADE IN COMPLIANCE WRH BAN JOAQUIN COUNTY DEVELOPME CHIApT 9-111 ,3 THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL N JOB ADDRESSOR APN. HEALTH Dq/IBGN, CITY 5 cktLrvl Z'37acits OWNER'S NAME iV/P/ O I !'; PARCEL BIIFJAM/ S�C�JG-C ApORf66 Y CONTRACTOR C ? y1 �I(L�� 1�j1, G�✓ — RIONE F L� Z PE68�CGIGTI VL 1 �` LICJ ' !� SUB CONTRACTOR v C 1 ✓U VVl r—,(� tC.f� PNDNE I&a - �p S$k Cr.L gyp, as b� -'1 PHONE/4 S-IS I I -vpc OF WEL4T11MP• ❑ NEW WELL ❑ REPLACEMENT WELL s f K P'—'ITj C7 MONITOMNO cY I ❑ OTHER ❑ INSTALLATION Cl WELL SYSTEM REPAIR ��0 ❑ CROBBC SET REPAIR ✓,F_3S ❑ VAPOR EXTRACTION WELL/❑N.❑Pep.lT H.P. DEPTH PUMP SETFT. TYPE OF PUMP K (i S FAST WATER LEVEL ❑DESTRUCTION: OUT-o"ERVICE WELL ❑ GEOPHYSICAL WELL J ❑ O � BOIL BORING 8 IJ :Ni ENOEO USE TYPE OF WELL CON{TRUCDOM SPECIFICATION{ ❑ INDUSTRIAL ❑ PE BOTTOM �1 0 r McNT}e Fc7 MA.OF WELL EXCAVATION N5q A -3 DOMESTIO/PRIVATE LPACX/B12E C...,.-I �-L CIA.OF CONDUCTOR CASING Q TYPE OF CA61NG/STEEI�_ 4-// SGheLI U ll e 4-V OM,OF WELL CASING---IllJ�11 PUBUC/MUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL ShcI1P W U-Ij� O,I :.J IRRIGATION/AG ❑OTHER _GROUT 6fAl INSTA SPECIFICATON ``�� R LLED SY GROUT SRAM NAME I V L} VYI QVl fi 1. MONITORING SEAL PUMPER: NP E :.PPROX.OFITHS{V IILYV ZZT ' beep � Ys/ ((/!'CONCRETE PEDESTAL 5(49DDESTAL BY OWLER: Y. ❑Na S 11 LOIXING CMESTER BOX/STOVE RPE L TTiC L MCv'iI'�' 0POaEp CON{TPIMTONIDNWNG METHOD: MU P z+ed D ROTARY AIR ROTANy AUGEfl I� S CABLE OTHER i HEPEBY CERTIFY THAT I HAVE PR1EpAPEp THIS APRICATION ANO THAT THE WOLBC WRL BE GONE IN ACCOPpANCE WITH BAN JOAQUIN COUNTY OPDINANCEB,STATE UWH,AND RULES µD ' GULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE .....PERFORMANCE OF THE NON(FOR WHICH THE PERMIT IB BSUED,I SHALL NOT EMPLOY PERSONS FORMACEOFSUBJECT TO WORGMR COMPPBHBATION LAWS OF CAUMMIA.- CONTRACTOR'S HIRING OR SUBCONTMCTINO SIGNATURE CERTIFIES 1 HE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WpNL FOq WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSON8 SUBJECT TO WORR014µ'S COMPp{ATION LAWS OF ".AUFOµIA.- TT,HE APPLICANT MUST CALL I4 IN ADVAN ICE,MR A`�EOUREO INSPECTIONS AT 12MI 4YJ4==, COMPLETE DRAWING AT LOWER AREA/PROVR)ED ;Inrvd x 'IA,�`—� WpI�G JnHs �_��Lj1�'P./� Vl U ROT FUN 10,w m Bull 6.i1. 'le NAMES OF STREETS OR ROADS NEAFEST TO OR SOUNOMO THE P110PPFTY. OUTLINE OF THE PROPERTY,GIVING AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYSIEI.1 Oq g QMSED ! DIMENSIONED OUTLINES AND LOCAnON OF ALL EXISTING AND PROPOSED EXPANSION OF BEWARE HINIVDISPOSAL IS OF O B. STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALJLS, I. LOCATION OF WELLS WITHIN ,,PR OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ApJOMING PROPERTY, j ....... .... ... ......6 .. T .. .d.......... r. _ , ..: .... ' OfPMTMpT USE ONLY p(Ocabn Aeeylnd BY "- - �—t��9 DbV �.. OrnN Irnpylyn BY Orts PunP lmPacBen By ptlS Osmmlbn In.ywlyn BT ' A K5 ,Cotu "--OUNrNG ONLY: AID/ FACJ PE COOFI FEE INFO AMOUNT RURITTEO GRECKIICAEN RECDVFD SY GATE PFIWHIT/SERVICE REQUEfT NWOM 0 INVOICE 0/ ��, Z