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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 ' (209) 458-3420 ADN REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Tri lkstbl 9"IfCA71ON IS HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDOOR INSTALL THE WOPX OESCRrSE0 THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TTTILE CHAPTER 11 111 S 3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH 1311,181ON JOB ADDAESWOR APNjV 151 S Afnl -57. CITY &7AA1;rdCJq , CR PARCEL SIZEIAPN/ OWNER 8 NAME I7,4/r.lr. _IAC 1,4,md'T.eyr r ,/ 0 ,2!_rATIel�/ _ ADDRESSJ7/J7S. jgjgACg M A 1 P..CAM"Bel a N- PHONE x6fe!U 37/-1000 I71g Zr- 9442;4 C.x' P!&CONTRACTOR,6 rJ-S TG TPr FIJI/ Ld P.. �1 _ — - ADDRESS I C ucrS!j 9v 5'! -PHONE,r f aY 371-LO? /53S..�yls/us7�Tr4t/?d8• 8U8 CONTRACTOR ICY 111.!!YF?T2 a J{Wg.4+v f V{[S?s ADDRESS S A N T w ,C 4 UCS V 9910 _ PHONE di"; 22 2 TYPE OF WELFJPUMP. © NEW WELL 13 REPLACEMENT WELL ❑ MONITORING WELL r ® OTHERS / Yu+Vd NA+A7t'AY" ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r CrC.►B�rTa^/IG 11 �t LLy��r+J _. ©N.ar❑R.p.lr H P Il DEPTH PUMP S£r P-5 FT FIRST WATER LEVEL t 1.JC(15 1 tTYAE OF PUMP/ ❑ OUT-CFSERVICE WELL ❑ OEOPHYSICAL WELL r ❑ SOIL BOrVNO 8 ❑DESTRUCTION IINTEN13ED USE TYPa OF.WEL� CONSTRUCTION SPECIFICATION& A 0 INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION / / DIA OF CONDUCTOR CASINO k1 hQ O ❑ DOMEBTICIPRIVATE ❑GRAVEL PACKISME TYPE OF CASINGISTEELIPVC PRIG DIA OF WELL CASING u•5 D ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 7-16 It __ SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT REAL INSTALLED BY GROUT BRAND NAME IQ _ E SN fe VEaNlt��AJ",l9d'' ❑ MBNtRY/FBHG 6-1'/l;Y nc.T/c w 'f�'� L�y GROUT SEAL PUMPED ❑YF. ❑Na CONCRETE PEDESTAL BY DRILLER ❑Yw 14N- 3 APPROX DEPTH 10 r 1 LOCKING CHESTER SOX/STOVE PIPE S PROPOSED CONSTRUCTIONIMI-LINO METHOD MUD ROTARY AIR ROTARY AVOER- )._ CABLE OTHER ' I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES ANO REOULATIONS OF THE SAN JOAQUIN COUNTY HOME OWNER OR LICENSED AGENT 8 SIGNATURE CERTIFIES THE FOLLOWING '1 CERTIFY THAT IN THE PERFORMANCE OR THE WORK FOR W141CH THIS PERMIT 19 ISSUED I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN a COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR S HIRING OR BUB-CONTRACTING SIGNATURE CEFrTIFIES THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS 18BUED I SHALL EMPLOY PERSONS SUBJECT TO WOR07AAN I COMPENSATION LAWS OF ALIFOR IA• CANT MUST CALL 24 HOURS,1N ADVANCE FOR ALL REOUIRED WS"ICT10N8 AT[20014"-S422 COMPLETE DRAWING AT LOWER AREA PROVIDED ' pnw X r+rf.JxL l.. ■`�I i f�aa _ Tme v Lg2/G o , 7/sf ? -- PLOT PLAN(Drew is Sams]SaN.�+ /_ to r 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY 4 LOCATION OF HOUSE BEWAOEJISPOSAL BYMM OR PROPOSED 2 OUTLINE OF THE PROPERTY,GNVINO DIMENSIONS AND NORTH DIRECTION EXPANSION OF BEWAOE DIDPO 8YSTEMB 3 DIF.RENBNONEb OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S LOCATION OP WELLS WrTHlN OIUS OF ONE HUNDRED FIFTY FT BTRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAY8 AND WALKS ON THE PROPERTY OR ADJOINI PROPERTY 1 O i �Y [ �• Fr M�/J� s7 I 'i S ' i 1 4 n 9 .� r • ' � + � 4 7 y 'vy � r } { b Elm, p 3 v v v ' } } D I } 4 S ro r v I ' DIPARTMENT UBE ONLY Anwllww,Mw Aw..�.rrN C.,