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APPLICATION FOR WELL/PUMP PERMIT 'N JOAOUIN COUNTY PUBLIC HEALTH SERVICEP ywr_ ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202--" (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete IR TtlpRetNl APPLICATION IR HERE BY MADE TO THE BAN JOAGUN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOrK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND TIIE ST `AN 'DARDS OF BAN JOADUN COUNTY PUBLIC NFALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOR AODRESRNn AP►�LNlf,,\�`L1%17- CQ-%f- EQQS J P Q V V�j VJU M CIIT�EY� >r icl i -kv, PARCEL SIZE/ATNF / OWNER'S NAME `•'•"`''T't'"j IF q�L V�Q~ ADDRESS T"'� v`FL�Q�_r "T'„�Mr�n � PHONE 0 �C�-�_pO`-, - CONIRACTOR 7VA%'T-� T_�<�A,cltny ADDRFBB�Zj`uc fi-� �L-4 Nr• UC,5IO�(�k rNGNE/5--* -'LZ?4 SUR CONTMCi On F\ .L" Q�t IO�VNL-M 1. ADDRESS J E rl X1.1 1`I u- L1CF(A3816-5-M/ONE TYPE OF WELL)PUMPI ❑NEW WEU. ❑REPLACEMENT WFLL 11 MONITOmNO WELL 0 ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR 11 CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL E J CIN-0lu.4 N.P. DEPTH PIMP SET Fr. FIRST WATER LEVEL O (TYPE Of PUMP L ElOUT-Or-BERVICE WELL ElOEOPIYSCAL WELLR Boa BORING 3 ro 30 B ❑DEBimICTK1N! PIN-,TENDED USE IPE OF WELL CONSTRUCTION SPECIFICATIONS A U INDUSTRIAL ❑IJ-TOPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CAMINO O 1J DOMESTICI PIVATE GRAVEL PACK/B/ZE TYCO OF CASINO/8TF.El/1'VC VIA.Of WELL CASINO O ❑PUKICOAUNICMAL 17 bmvEN DEPTH OF GROUT SEAL 3(- SPECIFICATION R ❑DIBOATION/AG ❑OTHER GROUT SEAL INSTALLED IV GROUT BRAND NAME `A N� E c)MONITORING EM IiS NG OROUT R MONITOPUMPED: Y, ❑Ne CONCRETE PEDESTAL SY OnILLER:❑YM E3< d APPROX.OM" , LOCKING CHESTER BOX/STOVE PTE 1� d PROPOSED lU CONSTRUCTIORMFENO METHOD:MUD ROtARY Am/IOTARY AUGER CAME OTHER T+\fit �Js� I IIE4ERY CEnHFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TIIE WORK WILL RE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.OTAtE LAWS.AND nULER AND r1FOLRATIO7 9 OF THE SAN JOAOIMI COUNTY.HOME OWNER On LICENSED AGENT'S 910NATURE CERTWIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK rOR W'IRCH /IRR PERMIT IR ISSUED,1 SHALL NOT EMPLOY PERSONS SUIIJECT TO WORKMAN'S COMPENSATION LAWS Of CALWOF"A.-CONTRACTOR'S HIRING OR SUS-COMPACTWO BIONATURE CERTIrWi THE FOLLOWING: '1 CERTIFY 11/AT IN THE PERFORMANCE Of TIIE WORK FOR WHICH 71115 PERMIT/S ISSUED,1 0/TALL EMPLOY PEnSome SUBJECT TO WORKMAN'S COMI ENOATION IAW2 Of CALWORMA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED .LfA 1 r1.IIRMPECTIONS�AT I"01�4�M-S422.COMPLETE DMWINO AT LOWER AREA PROVIDED. _ /IMAK �yYLdl 010wl X lvt Tit'. T-„,zaxta LLN Gate—`111 19-7,-7, MAN AN 0—1•'00001 BSN• 'to 1.NAMES Or STREET@ On ROADS NEAREST TO On SOUNDIM THE PROPERTY. 4.LOCATION Of HOUSE SEWAGE DISPOBM SYSTEM On PROPOSED 2.OUTLINE OF 111E PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPORM SYSTEMS. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION Or WELLS WITHIN RADIUS OF ONE HUNDRED rWTY FT. STRUCTIMEB,MICLUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING POPLRTY. ” HARDING WAY a SIOEWALe N 1 I AL1 EY ASPIIALt CONCRETE EC N FORMER x lG LMA 05PCNSER • PROPOSED BOHIIT101! LOCATION LOCe i-A„• RLDc SHED UST LOCAtIOIIS I'OhE MONARf-11 SIMSTATgN SITE PLAN 1112 EAST HORDING WAY STOCKTON. CALIFORNIA vARm roR EGGIMAN, ANDREW & EDITH TRUST SC'1E MOUNTAIN RANCH, CA I• a NF, SMTH FIGURE 2 I Of.►MTMENt Ulf!ONLY AnPBe•11en AeeepleA By D•1• � '2 �� MY OrmN IrrPeerbn Br Dee Pt"p IIRPeeeen Sy GN• D,wNllelbn MwPeelbn SY be• Cemm«Nr: ACCOIMTINO ONLY: AMI FACT PE CObts FEE INFO UNT REMITTED AIN RECDVED■Y OAJIFPEPMITISFRVICE REQUEST IAWAB[F1 INVOICE IS-6 I 4h- X19o S” 7 71 i" D/�? Pub.Health Sew.-Enviro.173(1/97)