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C APPLICATION FOR WELLIPUMP PERMIT 4IOSAN JOAOUIN COUNTY PUBLIC HEALTH SERVIC* ENVIRONMENTAL HEALTH DIVISION RO. BOX 38Q 304 EAST WEBER AVENUE, STOCKTON, CA 95x00388 (209) 488.3420 RON•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cornplato In Tdpneata) APPLICATION IS HERE BY MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.71118 APPLICATION IS MADE IN COMPLIANCE MT14 SAN JOAQUIN COUNTY DEVELOPMENT TUTU,CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADORESSIOR APHfI1 a PAUrlC— n•/ l k ' y CITi -�C KIAC) PARCEL BIZEJApNf 1, OWNER'S NAME__.VU'1U D£Pr( e�• gr �I S C� •.�/ 1 Orifi- P D, 4.Q�llQ1�s}r♦�K+On ��PHONE z�5) 7b ��y�r P.�.sz- r �ADbRE66 CONTRACTOR_ VOM£D Geo �n�I:a{,�mP.^+'I•CrA� ��r _ADDRe991�0 W. Mo N ----- //�� J � y� SUB CONTRACTORA�i�, &;)kA-:,J' CC ADDRESS!. L75 Z2� G141M>+ LICE 7 I PHO NE5L ! 6 TYPE OF WELLIPUMP. © NEW WELL ❑ REPLACEMENT WELL liq MONITORING WELL fmw +HW'y © OTHER f ❑ INBTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR Al W'q CR VAPOR EXTRACTION WELL f- yW'^I (TYPE OF PUMP► E]Now©Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL 1:1GEOPHYSICAL WELL f ❑ SOIL BOMNO S 11 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,Of WELL EXCAVATION �,e DIA.OF CONDUCTOR CASINO u/l A p 11Q 00MESTICWHIVATE GRAVEL PACK79l2E 7YPE OF CASINGMTEEUPVC DIA.OF WELL CASINO �� D ❑ PUSLICIMUNICIPAL ❑DRIVEN DEPTH Of GROUT BEAL'H'' dr 401 �-rJP SPECIFICATION SLy E a 11:1 /IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY TF E(0j LPIPC GROUT BRAND NAM[_E0 10 tj lz:E L�1 MONITORING GROUT BEAL R/MPEO: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:KYR NeCP' lost APPROX.DEPTH__ S�/ _ LOCKINO CHERTEn BOX/STOVE PPE -Y eS, •-- S PROPOSED CONSTRUCTTONfDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WRL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORMNANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSAT10N LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPNSATTON LAWS OF CALIFORNIA.' TELE APPLICANT MUST CALL 24 HOURS i ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120711 400 W27, COMPLETE DTUAWING AT LOWER AREA PROVIDED. SlpnedX r Th ST ,'� l (+ Dere � PLOT PLAN IDrrw to Seefel Seale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION► EXPANSION OF SEWAGE DISPOSAL SYSTEM@. S. 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 AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. S Approvtw Qix ra. �3r DEPARTMENT USE ONLY App9ea11an Accepted aY Dge� • 5 Arr Graut Impaction BY Due Pump Impeeltcn By Date 13-M Ilan impaction �jBy� Det. Commerxa: c-►LC-�v`w' Y-�^'�� 6�4bLf ACCOUNTING ONLY: A;DF FACE PE CODES FEE INFO AMOUNT REMITTED CHECKffCASH RECEIVED BY DATE POWITIOERVICE REOUMT NUMBER INVOICE {i D l Pub-Health Serv.-Enviro.173(3196)