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PPI KATION FOR WELLIPUMP PER SAQUIN COUNTY PUBLIC HEALTH SCES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 • (209) 4683420 NOIR REFIl11OABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Campl$te In MpRutt) APPLICATION IB HERE BY MADE TO THE SAN JOAOUfR COUNTY FOR A PERMIT TO CONSTRUCT ANDJOIL INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WrTH SAN JOA43UIN COUNTY DEVELOPMENT TITLE CHAPTER 9-1 11 S 3 AJ.,�N�D THE STANDARDS OF BAN JOADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION j_ JOB AOORESSIOR APNI C7� j ' 1G + I i ,v4- CITY �7G(_!4 4 J�� _ PARCEL SIZEJAPN/ � �" � 0 �Z ^ l �j4�J OWNER aNAME cl t✓=y7r.t } A � �r� 7 IZ • --ADDRESS ` ll��R ll__Pt10NE1_L�'�l y � 7yZ-I CONTRACTOR_ AA,!AI.,IAn�f 'c.� GCO SAV ,,trvF,I � .-- ADDRESS -1 I^:_9�ucr -� .c c"1 PHONE.zl4 RUB CONTRACTOR ADDRESS UCr PHONE r TYPE OF WELLIPUMP, x NEW WELL ❑ REPLACEMENT WELL jqMONITORING WELL 0 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL. J ❑Naw❑R.aah H P DEPTH PUMP SET FT FIRST WATER LEVEL O {TYPE OF PUMPI ❑ OUT-0F SERVICE WELL ❑ GEOPHYSICAL WELL t ❑ SOIL BORING F ❑DESTRUCTION INTENDED U44 TYPE OF WELL CONSTRUCTION SPECIFICATION$ �I A ❑ INWBTRIAL ❑OPEN BOTTOM DtA OF WELL EXCAVATION DIA OF CONDUCTOR CASINO Ni O ❑ DGME9TICfi'10VATE IKORAVEL PACKIBRZE#3 Siir„n TYPE OF GABtNO/STEE OIA OF WELL CASINO r'f O /q� ❑ PUBLCIMUNICtPAL ❑DRIVEN DEPTH OF GROUT SEAL �kt+$, l F I SPECIFICATION r~IG fii./Z �1J of ❑ IRRIGATION/AO ❑OTHER OROITT SEAL weTALLED 9Y _.) fL,+n t E. f l GOUT BRAND NAME P--e T L A,,,Q E KMONITORING GROUT SEAL PUMPED glYr ❑N. CONCRE. PEDESTAL BY DRILLER:I!y Yw ❑Ne s APPROx DEPTH /O F" , ! LOCKING CHESTER BOxIWOVE Pvc ba{ s PROPOSED CORSTRUCTIONRI)IILLING METHOD MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HERESY CERTIFY THAT 1 HAVE PREPARED THIS APFUCA"ON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES STATE LAWS AND RULES AND REGULATIONS OF THE SAN JOAOUM COUNTY HOME OWNER OR LICENSED AGENT s SIGNATURE CERTIFIR:9 THE FOLLOWING 'I CERTIFY THAT 1N THE PuWon MANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTIHO SIGNATURE CERTIFIES HE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WOMMAN S COMPFNSATION LAWS OF ALIFORNIA- THE APPLICANT MUST CA,�24 HOURS IN ADVANCE FOR ALL REBURIED INSFiiC710M AT 12"1400-3422 COMPLETE DRAWING AT LOWER AREA PROVIDED atoned x E T.._ gF F GPd c a/S i _ _ Dat. Qk PLOT PLAN(Maw t.Seat.}Sal. to I NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2 OUTLINE OF THE PROPERTY GIVING OfMENSIONB AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS 3 DIMENSIONED OUTUNFB AND LOCATION OF ALL EXISTING AND PROPOSED t LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED fIFTV FT STRUCTURES INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS AND WALLS ON THE PROPERTY OR ADJOINING PROPERTY 'AjoR Plo ry AddPrjov1r-) _ c. a Q P _ �`�� Orr 1tRITM' USE ONLY {7/camAf A.plIcalkm Ae...ted By 14 v ON. /L/ A,M Grout I—aactl.n a F I Oat. w 5Oma h.oaetten By Dota 0,wTi ot"Inar,el BY Dat. Comment. ACCOUNTWO ONLY AID# FACS Il PE CODEC FEE two AMOUNT RENOTTED CHECRIfCABH RECBVED Y DATE P91MOTfSERVICE REGUEBT NW813I INVOICE CJ L- 'Z w 7 b ,,,0 ub Health Sam .Enviro 173(1!97)