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• APPLICATION FOR WELLIPUMP PERMIB0 SAN JOAOUIN COUNTY PUBLIC HEALTH SER ES ENVIRONMENTAL HEALTH DIVISION PS). BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 488.3420 /'�, NON-RE UNDABLE PERMIT EXPIRES 1 YEAR FROM DA ISSUED emplefs In TrIlilkafel c, e, Ik I. Q. APPLICATION ISN BY MADE TO THE SAN JOAQUIN COUNTY FO A RMIT O CONSTRUCT gN0/OB INSTALL THE W01E(OE6CR1 D.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAN JOAQUINCOUNTY EVELOPMENT TITLE•CN ER 91-1116. AND THE STANDARDS OF SAN JOAQUIN CO NTY PUBLIC TIT BE ES.FNVIRONMENTAL HEALTH DIVISION. JOB ADDRE89roR A CIT^'IL_t A40^I G.c-C4 /��PARC,EEL SIZE/APNI OWNER'S NAMF_ 11 \1 Q y I' ]]IG VI f-C CL-C4 %}'' ADDRESS gyp,•-y�/'J U+ 1,✓1- �OS PYNI TC A PIIONEI �f J /1`-^ptj y(J�E� CONTRACTOR •C - D✓ GV 4 N @G -+ems 1��, ADDRESS T5-16C N r If7/C k L1C�E .I ^f�K(MINE I q65--e 6 "L(1-4 3V BUS CONTMCTOR S G ✓L•F PDI -� Man 5-1 jC K'�01/1 `��yr LACI/_1'J�µt�.y V(Jp110NEE 7V5 -e 712, TYPE OF WELL/PUMP' ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# L7'OTIIEP Cn W"• C-J110 to ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑N..v❑Rey.lr H.P. DEPTH PUMP SET R. FIRST WATER LEVEL D DYPE OF R/MPI ❑ our or SERVICE WELL ❑ MOPNYSICAL WELL# ❑ SOR BORING e ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION 6PECIFICATION3 A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC"IVATE DRAWL PACK/SIZE TYPE OF CASING/6TEFL9'VC DIA.OF WELL CASINO D ❑ PUBLICIMUNICIPAI ❑DRIVEN DEPTH OF GROW SEAL SPECIFICATION R ❑ IRRIOATR)WAO ❑OTHER GROUT SEAL INSTALLED BY BMW BRAND NAME E ❑ MONITORING GROUT SEAL WMPED: [IV. ❑Ne CONCRETE PEDESTAL BY GRILLER:❑Y. ❑Ne S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONIDNLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER - I HEREBY CERTIFY TIIAT I IIAVE PREPARED THIS AP%JCATION AND TNAT THE WD{K WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE SAN MAGIAN COUNTY. HOME OWNER OR LICENSED AGEM'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'6 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUR.CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIAN/-��NE�/APPLICANT1`(M/Ubi CALL I-I HOfW IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT VMG 448 422. COMPLETE DRAWING AT LOWER AREA PROVIDED. 81,, . X L 1 /�1.(/"� TIG. fIv.1 j (t!V v^c-c, inq 1 d D„. 7- / 7 9 E ROT MN(D'.1.Sete)Se.I. •Ie 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TIIE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR MoMSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NOW"DIDECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMS. G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE MPERTY OR ADJOINING MOPERTY. V1 1 .5 ,o cev vo a of Io r 1 'cri ti o ,' q n +olvLac �G�L/ © v� �auh t\J LrT� h7' yO c.va ,/ C1 cl OI IMI' Cil 5 1 in t> r'LM U 1. lJ ✓o b e 4L•:c 1. 4%0 (O �. Le bock4tI )eA ( U1 'f' t, vo4t wL,eLam; Cv� v1p1e4--ct �, oGa �"�ov► .... .. c ro.ac L, me ... .......... ......... ........... ......_ .. _ ..... ...,.. ..... TMENT USE ONLY 1 l Applleelbn A.eeplM By C EP be1. Ar.. _-(J 11IT11 ✓/L/ A/Vl1 01.A Iroveellen Sy D.,. Pump Imveellen 0, DH. Oe.ln.Gen Impecl.n By Del. cemmernr ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT"EMIIT-TTEED''� CHECK#/CAAH RECEIVED BY D TE P9MIT/SERVICE REQUEST BER INVOICE W Pub.Health Sew.-Enviro.173(3/96)