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APPLICATION FOR WELLTPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST. STOCKTON, CA 95201-388 (209) 4683420 ROM-REFUNDABLE PERMIT EXPIRES 111EAR FROM DATE ISSUED APPLICATION R HERE UY MADE TO THE SAN JOAOUN COUNTY FOR A PERff TO CONSTRUCT Amoco NSTALL THE WORK CE7C>VED.TMS APPLICATION a MADE N COL LL^NICE WITH SAN JOAaISN COUNTY DEVELOPMENT TTrLE.CMAIrETR 9-1115.3 AND THE STANDARDS OF SAN JOAOUN COUNTY PUSUC HEALTH SERVICES.EHvrLONIAEffAL HEALTH DIV11aoK JG,ADD„E,.,MPJ Af '}O750 Sc�1wV f- RA crr,- -1 r- PARCEL 252-040-07-- 71 OWHER•E NIA►_ ADDRESS l/ n P1gNE f '12 u coNTRALTOR tvlaTT; mADL)REq 1G0{0) Pine-Lc} • Ill Lsf P1pNEf N ...T. o zbh TYPE OF WrAMUM►: ANEW WE3L ❑ AEP ACDif@T WELL MGNJTTORNo WELL f 1'_- ❑ OTHER INSTALLATION ❑ WELL SYSTEIL REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J tt�.frwr❑P. H.P. DEPTH PUMP SET R. FIRST WATER LEVEL O TYPE OF PVMPf ❑ OUT-0F•SENCE WELL ❑ GEDPMY7CAL WHl f ❑ SOl Wlrq 8 ❑DEETRJCflON. INTONDEG USS TY►E OF WELL CONSTRUCTION 40SC3RCATIONS A ❑ SpUiTRAL ❑OPEN/OTTOM OLA.OF WELL EXCAVATION S l VLL`/1 DLA.OF CONOUCTORCAiq^ 904E O ❑ DOMEsnGPRVATE D GRAVEL PAOUS@ I/2.0 TYPE of cA mffrmA,%c5G1�1 40 �� olll of WELL cAso of ►n(.In O ❑ Pveul:AAxacrAL D DRMEN DEPTH OF GROUT SEAL 0 - ( L-+ log-j SPECiHCATION s c.�1 C].O t l NL.LI s 10*-- ❑ YIIOATIOIN/AQ D OTHER GROUT SEAL INSTALLED SY DROIT SRAM NAA* E 0LJONSTORRD GROUT SEAL TONY@ D Y- am. CONCJIETE P SOMAL r O1RLRt❑Y. ❑NN s APPIIDOL OSPTH ZCP'-+ b�5 LOCILSNS CHESTER SOIISTOVE PIPE ✓ S PROPOSp CONSTISIXTIONXIOULOW PJISTHOP. MLA ROTARY AIR ROTARY AUGM . cAelE OTHER HERESY CERTN Y THAT 1 HAVE PREPARED THIS APPLICATION IMO THAT THE WORK WILL R DONE N ACCORDANCE WTN SAN JOAQUIN COUNTY OIO4NCES.STATE LAWS,AND RULES AND REGUL.ATIONM OF THE SAN JOAOU IN COUIfrY. HOME OWNER OR LICENSED AOEHT-S DENATURE CERTWKS THE POLLOWIMI:1 CERTWY THAT N THE PESOIYMICE OF THE WoIK FOR WHICH THIS PEIAIT R ISSUED.I SMALL NOT EKSP OY P9YONS SU41JECT TO WOIKYAM•S COMPSIMATION LAWS OF CALiCRNII' CONTRACTOR'S NOW40 OR 9iI84N3NTIMCT1q SIGNATURE CERTIFIES THE POLLOWM.- 'I CETTTIFY THAT N THE PEPOIYAMCE OF THE WORK FOR WHICH THIS Pff fr M ISIOUED.1 SMALL E WPUDDYY PONIONS SUILJECT TO WOPWAAWS COPMKYATWN LAWS OF CALIFORNIA.* M A/RIGAM NOLIR/N ADVANCE PORI ALL RE�OI/RE C>SC�A`VP� l C/1 OMINNS AT LOWER O`PROVDEG. IAN 1 7 J5119(g-:4- PLOT PLAN 0--S..w Str- 1 u _JNOr- ."C fGA4- 1. NAMES OF STHELTTS OR ROADS NEAREST TO OR BOUNDING THE PROPERrY. 4. LOCATION OF MOOR SEWAGE LIIlOSILL SYSTEM OR PROPOSED 2. OUTLINE OF THE PIDLERY,GIVING OIMEVOONS AND NORTH OVIECTION. DCPANUON OF SEWAGE OISPOSAL SYREAL 3. DSLENSIOIED OLrrLmm AND LOCATION OF ALL EOOSTSfi AND PROPOSED L. LOCATION OF WELLS WfTHN RAMS OF ONE HILDOI®RPTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJ01Sir NIDPETY. ......................................................................................_._..._ _ .___ _.... ___. ..........................................................-......................................... ....... .... .................................................................................._..... .... ....................................................................................................... .... .................... .. .. .. :. :. .:::5� Tom' .::�w . GhIJ T:.. .:1�:: :::.a�i��'LA�.......::. OSARISSKff USE ONLY APPIkAr/wI A�-S STil � Do Z p-27 Arm Ob Grow hAwpaOI ST DA PLSIIi YNMn/I1 SY OEM Downw1wn Da ACCOUNTNO O/KY: AOf FACS PS coon PER 11110-0 AFAOUNT RKTTIM CM111M CASH I Rll: m lY OATS I PEMTAEIVICS PtECLOSIT NLJAwI UfMOICE ,o v 5-2-7471 tfiiw6w- 0210!