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APPLICATION FOR WELL(PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SEROS ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4693420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CGmpl$t$In TripOa$t$) AMMATION 18 HERE BY MADE TO THE SAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DE,ASJCD�RIBED.�T/H(1��A'�I��A�P'�P+;LICATION 18 MADE IN COMPLIANCE WRIT SAN JOADVIN COUNTY DEVELOPMENT THTEA�gg- IS.CI P111 S3 AND THE BTA PU DARO9 F BAN JO OUIN COU BLIC UI `�Y H ALTH DIVISION. JOB ADOREB9rofl AMR 7, /� p , (� qTf Mb'✓1 TQ,/ �+ PARCEL ZnF/AFNI �r OWNER'8 NAMES I' ofof /"}IAO YecI Cl ADDRESS R9� W' Ya SC-VII -j-e A04,VR, ;A e16 .2 CONTRACTOR( O NG�IOY I=oi/ 4-VF GG N W^G._ 9 L }� ��\ ADDRESS !(A}Y- 'U l'.LjC,. LN:I PHONE/ 666- -F� 3`� SUN COMRACTOR el--4 1-h [.� X . LC/t REBS S +OG: i<lv" G �,....�� LACI/y �d�•1K GZJ p1oNEF �` u7�Q) TYPE OF WELI/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL E] -)tLTMONITORING WELL P OTIIER L-7, L'V. ❑ INSTALLATION ❑ WELL SYSTEM REPAIR 11 CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑ p YPE OF RIMPI New 13 Flap.], H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D 1:1OVT-Or-SERVICE WELL ❑ GEOPHYSICAL WELL A ❑ SOIL BORING B 11 DEBTRUCTgN: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ DOMESTICNRIVATE ❑DRAWL PACK/SIZE TYPE OF CASINO/STEEUPVC DIA.OF WELL CASING D ❑ PVBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL SPECIFICATION R ❑ IMIGATgN/AO ❑OTHER GROUT SEAL INSTALLED BY GROVE BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DmU-ER:Ely" ❑Ne 5 APMOX.DEPTH LOCKING CHESTEn BOXMOVE PPE 5 PROP08M CONSTRUCTIUNIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APNICATION AND THAT THE WOW W M BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOEM'B SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISBUED,1 WALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMMN$ANON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR MR COMMCTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR NMICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- TIRE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSSMCTIONS AT 12")488,S422. COMPLETE DRAWING AT LOWER AREA P oMDEO. mm,M X �Cil.c�1_ TIP. / D 1 E3 Y G'O �b OI + V 0.—a— /7 '— 4(- MOT PLOT PIAN ID,.I.Sere)Se.l. -le 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF NOVBF SEWAGE DISPOSAL SYSTEM OR PIIOroSED _. OUTLINE OF THE RgPERTY,GIVING DIMENSIONS AND NOM"DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3, DIMENSIONED OUTLWFQ AND LOCATION OF ALL EXIMINO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED Fl Y FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PPOPERTY. e,VY1AIt . . c' PP l 'cA v-E CJ vP QPp /, u51, borT �: �Jof /� II G 5 — � � �:��y-a LID ' ale F, l,rgYV1(' fG' Y, /o� p/� m0l�7 fcClcq /4 rP/or+ A7F Y , T O ✓ co I t 6 C 4-1 uo . Y La b Sq e le 4 's , & S; VrY C4 1 to v�o h -ectiN© � �SY Borim, ) bc,C ,Ic 1 /&04 : L. ,i. �1 0jvou wHe" caw1P S G Hoc & 'qrp 5 aL, aca 1:10 G vcJUG LE vheH pe- Vvr, �7 Gf C hC'O1 l .. ADPII..tlen Amm1M BYDEFRAYMENT USE ONLY D t. G /J A,e. GreU ImDmlbn BY Dae Dene In.pmtlen By Otle Deav�e0en Imnmtbn BY O.ta Cemmnn. ACCOUNTING ONLY: MDR FACE PE CODES FEE INFO AMOUNT REMITTED CHECIUNCAM RECEIVED BY DATE FERMI IS MC RED NUMBER INVOICE © f I 17 Pub.Health Sew,-Enviro.173(3/96)