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APPLICATION FOR WELLIPUMP PERMIT D OtOO Z z SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O.BOX 388,,304 EAST WEBER AVENUE,STOCKTON,CA 95 I-M 12091 462•3420 0019•REFUNOANLE PERMIT EXPIRES 1 YEAR FROM GATE f3sufO ICBeFIIES ID TEIprmsa) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PEIMATT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN CrAAPUANCE NATE!BAN JOAQUINCOIAVTY DEVELOPMENT TITLE.CHAPTER 0.111 5.3 AND THE STANDNOS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DR.ISION, JOB ADDREIIAR AFRI �Ql � CRY �"y�L4.,d r PARCEL 812EIAPk1 4P �-675! OWNER'S NAM_E �1J� AD.DRESS CawpACTOR ADDRESS STIR CONTRACTOR ADDRESS UCS PHONE TYPE Df WElJAUMP ❑NEW WELL ❑REPLACEMENT WELL ❑ MONTOPNa WEtt! ❑OTHER_ ❑INSTALLATION ❑WELL BYSTEM REPAIR ❑CRO86CONNECT REPAIR ❑VAPOR EXTMCTgN WELL/ J ❑N—❑Raa.lr H.P. DEPTH PUMP SET FT. FAT WATER LEVEL O (TYPE OF PUMP/ J( 11,O{)UT-OF�SERVICE}YELL ❑GEOPHYSICAL WELL I 13 SOIL BORING B x...UCTON: j' EQ / �'E�/� 44 abuia INTENDED LIBI TYPE OF Wfu CONSTRICTION SPKiICAT10_N& A ❑INDUSTRIAL ❑OPENSOTTOM DfA.OF WELL EXCAVATION DIA.Of CONDUCTOR CASINO 0 ❑DOMESTIC/MVATE ❑GRAVEL PACKISCE TYPE OF CASINWSTEELPVC DIA.OF WELL CASINO 0 ❑PURUCRAUNICIPAL ❑DPoVEN OEM Of GROUT SEAL _ SPECIFICATION R ❑SWGATON/AG ❑OTHER GROUT SEN.INSTALLED BY GROUT BRAND NAME E ❑MONlTONNG OROUT SFµKIMPED:❑Y. ON. CONCRETE PEDESTAL 8Y OWLLEK:❑Yr ❑Na S APPROX.DEPTH LOCKING CHESTER SOXIBTOVE PIK S PROPOIED CONSTRICTION(DISLLREO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9ERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND T14ATTIOE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICEHBED AGENT'S SIGNATURE CERTIFIES THE POLLOWINO:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO W01110am'S COMPENSATION LAMB OF CM.IFORNIA.•CONTRACTOR'S HIRING OR BUBCONTAACTNG SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR W1CCH THIS PEMMT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO Wopjmtm'S COMM/ATIGN LAWS OF CALIFORNIA�.• T./FI/E/,JAPPICANY MUST CALL N HOU S IN ADVANCE FOR AL•.REQUIRED INSFECTIUNI AT IBOA14SS313S. COMPLETE DRAWING AT LOWER AREA PROND ` Bllnae x_ _((. [A ��. '7 1'ZZ✓E✓L Tltl. JO I-e-!P' Dat. / 97 prONl PLOT PLAN(D,—ro SUIN RUN to .t I.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. a. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 7.OUTLINE OF THE PROPERTY,OIVRFO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE 040POGAL SYSTEMS, 3. DIMENSIONED OUTUNFS AND LOCATION Of ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,WLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALES. ON THE PROPERTY OR ADJOINING/TOPERfY. ' p IY Ai ��pp .E�I+1� WA.. (G. y Dov 4 1997 -------------- -AN JOAQVIN COUNTY f i U6LiC 11E:A1,Tk 9FIRVIe--$ i FrHVI17EN1AgEdHT�},I'lEALT1H'pMSION .• .... .. ...... TrtPARTMENT USE ONLY APpRG,llm AccgrM BY__� DMa Arra � tf-- Ore.Impnatbn 0Y— Data Pvnp 1rAPAetbn BY �pate artriretbn IraPaelbn RT DNa Z Commoner, t �h! ACCOrJNTINO ONLY: Al. FAG IKi COVES FEE INFO AMOUNT REMITTEDC K/ ASH RECDVED■Y DATE PtRMITNBIVICE AEOIJ'T7T NUIASSR INVOICE ` v6a �c v 9 / / sl�3S