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APPLICATION FOR WELIJPUMP PE AQUIN COUNTY PUBLIC HEALTH CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (COCIIIII 1 APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTANOF/OIRI INSTALL THE WON(DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TIME.CHAPTER 9-11///1 yyy5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY MBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMR AAM ��y �/J / „ 1(„ f ��RIIL CITY p/- �y� '7p I^ r"-E-- a,un�. kbnq {'s �� "O� PARCEL SIZE/ARI# l/>7 OW IFFI'6 NAME /I T)n a�� 'B d -T!I "l S C�r�F ADnREee9y(op.378??- COMIUCTOR ADDRESS LICE RIONE I PUB COMPACTOR l_ r-1_� .�Tloc�� ADDncse Ma fi c r�Rp 9H ST2 u CA ---gyp yoS/ F NE,tj zrr S-8p0 TYPE OF WELLJPUMI ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL/ -a ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL ❑New H.Pelr H.P. J RYPE OF RJMPI DEPTH WARP SET ST. FIRST WATER LEVEL__ ❑ El OUT OF SERVICE WELL ❑ GEOPHYSICAL WELL, ❑ SOIL PORING O DESTRUCTION: B INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOMA DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING ❑ DOMESTICD'RIVATE 11 GRAVEL PACK/SIZE TYPE OF CASINO/BTEEINVG D PUBIICIMUNICIPAL 11 DRIVEN DEPTH OF OgOUT BEAT DIA.OF WELL CASINO D 11IHRIGATMNIAG 11OTHER SPECIFICATION R GROUT REAL INSTALLED BY GROW BRAND NAME 11 MONITORING GROW SEAL PLIMPED: ❑Ys ❑N. CONCRETE PEOEBTAL BV DRILLER:❑y.. (]WS APPROX.k.DEIN LOCKING CHESTER BOX/STOVE PIPE PROPOSEQ CONSTRUCTION/ LIUNG METHOD: MUD RpTARyS Alq ROTARY AUGER CABLE. OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED TNIB APPLICATION ANO THAT T"-WILL RE DONE IN ACCORI)gNtE WITH BAN JOApE U1N COUNTY ORDINANCS,STATE IAWe,AND RULER AND REGULATIONS OF THE SARI JOAQUIN COVNTY, HOME OWNER OR LICENSED AOEM'B SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF TIIE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA.' COMIERTIFY THAT NO OR OUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CEMIFY THAT IN TIIE PERFORMANCE OF THE WON(FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMANY COMPENSATION LAWS OF LOWER AREA N'S PROVIDED. COMP CALIFORNIA.- THE APPOC NT MUST CALL 24 MUM,IN ADVANCE FOR ALL REQUIRED INSKOTIONS 21x 1.AT 11 4441 COMPLETE OIUWINO AT LE. TIG.�A._��ro,�pr AOT RAN IDr.w 1.a W.l Sc.le -N I. NAMES OF BISECTSMOR ROADS NEAREST TO Oq BOUNDING THE PROPERTY, 2. OUTLINE OF THE PIKIAR AN LOCA ION OFlA L AND NORTH DIDECTION, a LOCATION OF"OUSE EFWAOE AL SYSTEMS.SYSTEM DR ITGAI6ED ]. DIMENSIONED OMLMEB CO LOCATION OF ALL EXISIN PA NO AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. STgVCTVREe,INCLUDING COVERED AREAS SUCH All PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. W LINCOLN RD - I- ---..—_ I1 NZW,I-IDEA•• W-7006 ❑�LLpCOLNI ELE{AENTARY SCHOOL Proposed oQ - (> Well Repair G p p MW-8 MW-10BANK OF -7 OF 6�TOCKiONV! GE AMERIG CLEANERS , ,, ¢ - S 8E T NW-7 ,, , OL E R uES .I 1#7 MW-107 MW-II 1 21 RW-100 •NW- '�. MW-2038(1.213) CNFv,Spry•Amm-6� I, PI VM /i 0 50 / Buw / /�/�� DEPARTMENT USE ONLY S- 22'2:2 7�i `,''.��y', APPII.mi.O M."WO BY<'J�?�- ION �+- 2 Z' / / a,uu11mP.=IIen BY —'---/— O.Is PbRP Impmg.n ev Oels D..W.H.rt ImP BY Geta - ca - 7g IK , (outbv,d d �Gwun �prias¢andnnm 5129'�- ACCOUNTING ONLY: AIDp PE CODES FEE INFO AMOUNT REMITTED CHECKRICAS14 RECEIVED BY DATE PERMITISEIIVICE REQUEST N,NnW INVOICE 274 9,225 4 Pub.Health Sew.-EDVIfO.173(1/97)