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00 APPLICATION FOR VVELL(PUMP PERMII� SAN JOAOUIN COUNTY PUBLIC HEALTH SER S ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209( 4693420 POR-REFUROARLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICormi In TrIpIkELEI APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMn INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WHIZ SAN JOAQUIN COUNTY DEVELOPMENT TRLE,CNAPfER 8- 115.3 ND TI1E STANDARDS OF SAN JOAOUIN COUNTY UC IIEALT 1 BERVICEB,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMR r ry/�^ �lU fj d'E3N ♦A CCT LN"� povin ✓ CIT-V MSN 'TcXyE /* / PARCEL 8IZE/APNI OWNER'S NAME-.<:J '�\/ O' - /�1 L�%1 �G C q ADDRESS r� F] (��`L� I T PHONE It ati / rJT CONTRACTOR I'— YI GY G Y C GAY �N �(�,C✓1, ,!{. ADDRESS �Y�G(,I� UCcI SUN CONTRACTOR (EI �OCk TyG u / % / 6 f8 - "];f 3� h rz Ae PHONE /}y rF--,� �� TYPEOF WELLIPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL U-1<0.RORING WELL INSTALLATION ❑ OTHER ❑ ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ❑New❑ J Rmelr N.P. DEPTH PUMP SFT RYPE FT. FIRST WATER LEVEL OF RIMPI __ O ❑ OUT-Of-SERVICE WELL ❑ GEOPHYSICAL WELL A '7V S BOIL SOnINO 5 3� 'C�(�(J N ❑ DESTRUCTION: INTENDED UCE TYPE OF WELL CONBTRUCTIOH SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONA DIA.OF CONDUCTOR CASINO ❑ OOMEBTICB'RIVATE ❑GRAVEL PACKlSIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO O ❑ P RIGATI UISCIPgI ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ❑ IRRIGAOMNO ❑OTHER GROUT SEAL INSTALLED BY R r-r/ GROUT BRAND NAME F L7 MONITORINp GROUT SEAL PUMMD: ❑Ym [IN. CONCRETE PEDESTAL BY DRILLER:Ely. ❑Ne S APPROX.DEPTH LOCKING CHESTER BOXWOVE%M 5 PROPOBFG CONSTRUCHONIORLUNQ METHOD: MUD ROTARY AIR ROTARY AUGER L CABLE OTHER__j� 1 HERERY CERTIFY THAT 1 WAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWN ANO RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMR IS ISSUED,1 SHALL EMPLOY PE090NS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T—apt\+q1C ANT MUST�CA�LLL UEO 24 HOURS IN ADVANCE FOR ALL REQRINHIMTIONS AT LUNG 4"S 22. COMPLETE DRAWING AT LOWER AREA FRDVIDED. n ef' X \ �... Lt TIGe l ✓c J'ec C--%--& OL{ 1 `, ,� MOT MAN ID,.m%W.l&.I. "t. / 1. NAMES Or STEMS OR ROADS NEAREST TO OR BOUNDING THE PgMM. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PIKIPLISEO 2. OUTLINE OF THE PROMErry GIVING DIMENSIONR AND NORTH DIRECTION. EXPANSION OF SEWAOE DIBPOSM-SYSTEMS. 3. DIMENBpNED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED PIETY FT. STRUCTURES,INCLUDING COVERED AREAE SUCH AS PATIOS,DRIVEWAYS,AND WALK$. ON THE PROPERTY OS ADJOINING PROPERTY. Tti :S erm, P 4" _a p p I ° ca'¢'Foh °'PP 11E' s 16 �I'- bo.vl 4, 5 t o �' M�> e G J {9 ' C.(a p s h; wq ,�; P In f, C 5 — J CG,vQ n Sa,L,p le o- /J ';o oecep a1 r r t p u 517 5+TNu ) pru b c� y', c� �1 ✓vl sra vl yta 1e �' of V-0 q ¢Sof IukrH P IEY � c J 1 J. J a G S - '3 C� 5 _ bo '>< tE s cvvi a cis p- P e z c&I,C �J I© � o�I[A 0i- ti c re bC, awT� fe r Ccs L,4r le �cZ)cq u,', 4- ti J '�, J'(1( . 7 h � D Deep Gva 13 Sc4L„p 'le) y ✓``ab S LAnpleo1 w 4' 11 S; :vr44 IPvc'''b o� ✓�J / F h 'fe r t c9 5 10 ru 14 4-CIC W c';cd rov C-0 c:C4IrOl!1 � I /) rj // DEPARTMENT USE ONLY noon..een A.emeo-1 By +�.F((/ (/�(..Y/�� Ona / W A,ee��..1 mem Imoe.11 o by D.R. %>nP In•Pmnen Br D.I. Dnbumlen Imnealon By D.I. Gemmae.: ACCOUNTING ONLY: AID/ FACE PE CODES FEE INFO AMOUNT REMITTED CNECK/ICAS" RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE Pub.Health SON.-Enviro.173(3/96)