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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,445 N.SAN JOAOUIN ST.,STOCKTON,CA 96201-3118 120914611-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CamplEtB In TFipucou) APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDAJR INSTALL THE WORT(DESCRRED.THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111115.3 AND THE STANDARDS OF SAN JOAOUIk COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. /$ JOB ADORESSMM APNr_1 7D,2--J&A-5a, `7 fr-e-g-t CITY _ �SCq/4*P PARCEL ORVAPNS OWNER'S NMIE m F=k L /H AODRE662�'V♦� f �7 /��f[SLL_E=�-j.� CONTRACTOR 1 AU`tlDRSS L 1_�') am CONTFACTOR ADDRESSO65-57 t nn OF WETIJPUMP: ❑NEW WELL . ❑HEPACEMENT WELL ❑MONITORING WELL 1 ❑OTHER Cl INSTALLATION ❑WELL SYSTEM REPAJR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL 0 J 13N-❑R", M.P. ET DEPTH PIMP SFT. FIRST WATER IFYEL p ' Rl'PE OF PUMP _ _ �{-T1 �I��,i/. /yy'�/I✓/VT _ ` ❑OUT-0FSERVICE WELL L..I OEOMYSICAL WELL F[f / L.J BOLL 9pIIIN0 g I IU DESTRUC uc[f./1L �! .� RTENTIFD USE TYPE OF WELL CON{TRIMTION iPCIFICATq N{ 1 Y �I(�,IfiG'�p � E✓i7 A ❑INDUSTRIAL ❑OPEN ao7TOM GIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O 1P-3I DOME6TKIPNVATF 13IBI GRAVEL PACITE TYPE Of CASINGlSTEELJPVC -OIA.OF WUL CASING 0 p PUSHCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFIOATION A ❑IFRROATIOINAG ❑OTHER GRODT SEAL tW ALLED BY GROUT SPANS NAME E ❑AIONITORINO OROUT SEAL PIMFEO:❑Yr ❑N. CONCHETE PDEBTAL BY DRILLER:❑Y.. ❑N. 9 APPROX.OWTH LOCXWO CHESTER SOX/STOVE PP S PROFO{ED CONSTEWTIONmmLNNO METHOD.MUD ROTARY AIR R07AKY AUGER CABLE OTHER 1 HERESY CERTIFY THAT 1 HAVE PREPARED THIS APP1CAMN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WEEN SAN JOAQUIN COUNTY ORDINANCES,SFATE LAWS,ANO RULES AND REGULATIONS OF THE BAN JOUMIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CETITIFIFSTHE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WOIK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTORS WRINO OR SU&COHTRACTING SIGNATURE CERIUIES THE FOLLONSNO: 'I CERFIFY THAT IN THE PERFORMANCE OF THE WORIC FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORRMAN-4 COMPOVEATION LAWS OF CALIFOR4A,• THE APPIJCANT MWY;=IN AOYAMCfi FOR ALL RFOWIFO IN{PEC710N{AT 12001 4884Ia22.COMPLETE DRAWING AT LOWER AREA PROVIDED. PO k Mt-S..W II.I• 'to 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE WSPOM SYSTEM OR PROPOSED 2.OUTUNE OF THE PROPERTY,DIVING DILEFNSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OUTLINES AND LOCATION OF AIL EXISTING AND PROPOSED {.LOCATION OF WELLS WITHIN RADIUS Of ONE HUNDRED FIFTY FT, JTFRICTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAJJV. ON THE PRDPFJYTY OR ADJOINING PROPERTY, 11 L%YPIMOLW STA7ll n r O ' AY'twl.Lne•,L Loi : x_10 La,[1,I,IE ................ QAC r6NOSLaAIw„ l:lIEFUALIZI.P :MIR TIMI -- ' WiLLIQI; l EKHOLM PROPTHIY .. . • WMAIDI6DG WELL 1702 JACKSON SIIICR-I 1 ESCALOII. CM.RFONIIIA '.,,....'.......... ..: o YAI'gI T.XTRACIroII WELL MRS. MARGRET CKH01-M -.... .: ..... ,,. ,w1L r:•,•/q�y'.1 ... r. e. m • m IFI, 1�L+S.-_`i3y}er_ IIC.IINF 1yjj.• //,A 1 OEFARTMENT USE ONLY /q6 App4 fuU A.."BY V OH. '.] f x.. O,auI.EWP•etl•a BY D.I. P p In•Pkllon aY D•s. P•.1„ySan I.w.cllon ST D- ......G -ACCOUN..G ONLY: ANDA FAC* PE Co.. FEE INFO AMOUNT ROWITED CHECRIIOAIH RECEIVED BY OA E PER OWSERVICE REOuLaT NUMBER INVOICE 3 a0 D- ;v;z� u