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APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209)485-3420 EIOMNEFUBEIABLE PERMIT RE! I UAN FROM VAT1339EB ICMlpkm M irMBeH.1 APPLICATION 19 11F.RE BY MADE TO THE IAN JOAQUIN COUNTY FOR A PEFAB I TO CONBTI4JCT AND/OR INSTALL THE WON[DESCRIBED.TIN@ APPLICATION ID MADE TH COMPLIANCE WRIN SAN JOAOUIN Co1NrY CEVELOPMENT TITLE,CHAPTER V-1 1 19.3 AND THE�ARDS SAN JOAQUIN COUNTY PUBLIC FIEALT Of Ea.ENVIRONMENTAL HEALTH brO N, Joe ADOI¢SSJOn APNf: CDY PARCEL SIiE/AP+ X2.3 -230-1 3 OWWR'r NAME v&vADDFESr dy CONTRACTOR ADD11Err .W LICI PF10NE+9 71�f] 1 BUD CONIHACTOR ADOR188 rmt*or TYPE OF WE1.L/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MOWTONNG WELL i ❑ OTHER_ ❑ INeTALLATIUN ❑ WELL rmEM REPAIR ❑ CROBI-CONNECT REPASS ❑ VAPOR EXSRACTPON WELL I 1 ❑ H.❑11Mr4 H.P- DEPTH PUMP BET FT. FMOT AT'ER LEVEL O RYPE OF PUMFI ❑ OVT-0E-SERVICE WELL ❑ OEOPHY8ICAL WELLYBOIL SORMNG l:( B ❑DESTRUCTION: VeIc INT TYK OF CONSIWJCIMN SPECIFICA ON$ �j A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION L + 41A.OF CONDUCTOR CABN10 O ❑ DOWETICMMVATE ❑GRAVEL PACKMZF TYPE OF CASINGMTEELIPVC CIA.OF WELL CASINO O ❑ PUBLICMAUWWAL ❑DRIVEN v DEPTH OF GROUT DEAL _ SPECN1G1TbN 11 ❑ IN ST❑OTHER GROUT SEAL STALLED BY RDUMI _ Of BAQ NAME MONITRING GPOUT SEAL PUNME 9 ❑YM ❑IN CONCRETE mmovAL BY DRILLER:❑Y. ❑Ne S �r�'�c AFPRO71.OEITN 2b � LOCKING CHESTER eOX1BrOVE PIPE /��` S NIOPOSM CON STR11CHON/0"U)NO METNOD7 MUD PIOT _AM ROTARY AUGER_ CABLE OTHER�--+ I HERBY CERTIFY THAT 1 HAVE FR[PAFEb THIS APPLICATION AND THAT THE WOW WILL BE DONE M ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REDULATIONO OF THE SAN JOAOUIN COUNTY. HOME OWNFR OR LICOMO AGENT'S OIONATURE CERTIFIES THE NOLLONANGt'1 CERTIFY THAT IN THE PEP FONAANCE OF TIIE WORK FOR WINCH TWO PFFAW IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKIMAII'O CoMPIeMOA710N LAWS OF CALIFOIMIA.' CONTRACTOR'!RAISING OR SUBCONTRACTING SIGNATURE CERTIP1Er THE FOUOWINO: 'I C IFY THAT IN THE 11"MIANCE OF THE WDI K FOR WINCH TWO PEP+JIT 18 ISMWJ,1/HALL EMPLOY PERSONS OLWECT TO WORMAN'S COMPBpAT10N LAW/OF CALIFORNIA T ANT MUST C ADVANC■FOR ALL RE41UIpW 710TH T I2rwjAwv4 Mlr. COIMIR"[DRAWING AT LOWER AREA PROVIDED. mwd x TNA. Dala _ /LOT PLAN 10,e to Soviet rude I- NAMES OF 1TIEErr OR NDADS NEAREST TO OR BOUNCING THE PROPERrY. 4. COCA?"of HOUSE SEWAGE DISPOSAL SYSTEM DR P mPOSW �V{ x. OUTUM OF THE PROPERTY.GIVING DNMENAIIONS AND NORM DIRECTION. EXPANOpN OF 1EWAGE OIOPOW SYOTDAV. !. bIMEN61014E17 OUTLINES AND LOCATION OF ALL EXISTIIG AND PPOPD*M S. LOCATION OF WELLS WITHIN RAbWs OF ONE HUNUDIEO FWrY Fr. �} lrrWXTVPES,INCLUDING COVV*O AREAO OWN AS PATIOS,DRNEWAYS,AND WALKS. ON THE PROPERTY OR ADJOBVRIG PROPERTY. 1} Kl- �_. ' ARTMINT UOE ONLY &9- APP1a.Nert A.wry.d BYE / Def. r Ac. Grew kq4.w.BT_ j Date R PL.M 1 mpmlhn er OM. r Oealn�adan InaPaella.+6Y401 DI[e C.�nmerKa:_ ACCOL"WdlONLT: AIDN FAC+ BD 1 -713 N CODES FEE Iwo AMOUNT PWMTTED CHECK+/CASH nw Y DATE P@MHDTMEIIVIC INVOICE 2-7 0 I R� 015 35 r 0 Put HesM Serv.-EnvirD.173(1197) l