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APPLICATION FOR WELLIPUMP PERMIT" SAN JOAl2UIN COUNTY PUBLIC HEALTH SER,._cS ENVIRONMENTAL HEALTH DIVISION P,O.BOX 388,904 EAST WEBER AVENUE,STOCKTON,CA 95201388 (209)488.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Campkh In TTiplk$tE) APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPUANCE WITH S JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLICHEALTHSERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSORAm#2 90/91 1 awmis Af 5nd cm s7C�L-.Y'TY^ PARCEL SIZE/APNO 17 y OWNER'S NAME�1JO GhN Ems\M��and- !jA re ADDRESS.2 �nnrJr/�$2d,S'�rr_��,s PHONE/�G-OG7Q- CONTRACTOR \� L~ J �,, // /moo•Sp>K 3 e- _1 /�.! ADORE66 /Lio 121 sig `�4.$7/ UCf7Z+O9O4 g1ONEf 3']d..7.8/.5 SUB CONTRACTOR ADDRESS lice PHONE S TYPE OF WEU-PUMP. ❑NEW WELL ❑REPLACEMENT WELL Pal�j-MONITORING WELL/ ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELLS TYFE OF PVMPI 13N-0 R.pk M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ❑OUT-O"ERVICE WELL ❑GEOPHYSICAL WELL I ❑ SOIL BORING ❑DESTRUCTION: INTENDED VfE TYPE OF WETS CONSTRICTION iPFCIFICATION$ ❑INDUSTRIAL ❑qq OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CANG ❑DOMESTIC/PR IVATE RW GRAVEL PACK/SIZE 7,//Z�/Z TYPE OF CA61NG/STEEUPVC. � D 5/G DIA.OF WELL CASING_' Z" 11M PUBLICUNiCIPAL 13 DRIVEN DEPtHOFGROUSI T6EAL STJ�IY�dCG SPECIFICATION .Aa4 40 �❑1 IRRIGATION/AD ❑OTHER GROUT SEAL INSTALLED BY Iy4�7gC&r- GROUT BRAND NAME Lal T� 1 R MONITORING Q GROUT SEAL PUMPED:WYr ❑N. CONCRETE PEDESTAL BY DRILLER.Cl Y. apNo r APPROX.DOTH BO/ LOCKING CHESTER BOX/STOVE PIPE—_X PROPOSED CONSTRUCTION/DRILLING METHOD:MUD ROTARY AIR ROTARY AUGER 1( CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AI REGULATIONS OF THE BAN JOAQUIN COUNTY.NOME OWNER OR LICENSED AaENT'1 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHP THIS PERMIT If ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFI THE FOLLOWING: 'i CERTI THAT N THE PEIIFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS CAUFORNIA. TH APP C NT MUS CALL 24 HOURS IN ADVANCE FOR ALL REOWLED INSPECTION$AT 12061 46$0422.COMPLETE DRAWING AT LOWER AREA PROVWED. slow xTIu•_Lyf�>R�7al�r D.t.t31 d1g 7 PWT PLM 0—W Sa.l.l 6-I. •to 1.NAMES OF RESTS OR ROAD$NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATIONOF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 9.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH M PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. HW 3 . : . i i OA:.... .. 87eY ... I RAPT baaiwLRT ..., -Elevation _41,. . �V 'LCC A 801 Tioit 1 ..� .AnV— .4 Elg(lJlsi�CieD$DIBRce� CONCRETE PAD: i .......:..... :... ... d 91t0F 8 BUII DING... 10 . $levat n 23: P !. ...:...... ..f .. .' . ........:... O 40 DEPARTMENT USE ONLY ` /' Cj APPllutbn AooYt.d BY �! D.NL Groh InPr,ctbn BY D.t.q 14 12 p—, t D.t. Owvwtbn InP.oOon BY D.H Comm.nt.: ACCOUNTING ONLY: Ap/ pAD/ PE CODES FEE INFO AMOUNT RFIWTTED CHECIKOXASH RECEIVED BY DATE PW MT/SDMCE REQUEST NUMBER INVOICE