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„gyp po ya1� APPLICATION FOR WELLIPUMP PERMIT SAN JDAOUIN COUNTY PUBLIC HEALTH SERV ICES o o yo re ENVIRONMENTAL HEALTH DIVISION RO. BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 9S20i388 (209)468.3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED -- IC.RIpYt.In TElpl'ic.1.1 APPLICATION IB HERE BY MADE TO THE SAN JOAOUSI COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MAGE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11116.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY FusLtc HEALTH SERVICES,ENVIRONMENTAL HEALTH DPA ON. JOB ADDRE89/OR APNO_.Il 32-3 6-- (,)/Qw COY �(n” - PARCEL 812E/APNI ONTIEq'B NAME_ L�LJ E`L '�E Cl"WL1N f ADDRESS saMo k-�• '�L i CONTRACTOF CL �IC 1 AODMOR T-U 2 V ,Ch4 rrtl- E g 71 BONE f E� PHONE E I SUB CONTRACTOR AD011E6B I1CO PHONE O TYPE OF WELLMUMP: NEW WELL ❑PEPUCEMFNT WELL ❑MONITORING WELL O ❑OTHER �{ S I [IIINNSTALLAM' ❑WELLL BYGIEM REPAM 11CROB"ONNECT REPAIR 11VA R EXTRAC7ON WELL I � J I.3 (:�,(, h H.P. (,� DEPTH RUMP SET H YPE OF PUMP) N^^"❑Z, FT. FIRST WATER IEVEt O ❑OUT-Or SENVOE WELL ❑GEOP14YSICAL WELL O ❑ SOF NG B BORI 11 OE9TItVCT10 N; C LE IFNDED UfE TYPE OF WELL CONtTB1UC 1—SPECIFICATIONS - � . EEy1 P)MVST' �� !2" •�ooMESTICIRLVAtE �❑�OPEN BOTTOM / DIA.OF WELL EXCAVATION cn GIA.OF CONDUCTOR CASINO LJ•ORAVFL PACK1.12E 2 l TYPE of CA61N0/6TEEVPVC_ Y (Y D /^�6 � DIA.OF WELL CASINO ^ C Cl ❑PU ILICiMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ZI/6 1 WTCIFICATON A ❑IRRIGATION/AG ❑OTHEqGROUT SEC C (NIL�L R w AL INSTALLED BY IC OgO1PT BnANONAME W E 11 MONITORING n( 1.L1 GROUT SEAL PUMPED: r ❑Ne CONCRETE PEDESTAL BY DRILLER: ❑Ne S APPTIOX.OETRN J O V( LOCKING CHESTER BOX/ oVE RPE a \ I PROPOCED CON9TIIUCTIONIORILUNO MFTHGO:MVD ROTAgY MR ROTA/TY AUGER CARIE OTHER I HF WRY CEIRIFV 714AT I HAVE PREPARED THIS APPLICATION AND TIIAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY OTOINANCEB,STATE LAWS,AND RULER AND nEOULATIONS OF THE BAN JOAOUW COUNTV,HOME OWNER OR LIOENBED AGENT'S SIGNATURE CERTIFIES THE FOLLOYMO:•1 CEREIFY THAT IN THE PERFORMANCE OF THE WORK FOR VAnCH\,J" THIS PERMIT IB ISSUED,i SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOF'B HIRING OR BUB{ONTRACTING 61GNAT VRE CEiRIFIE6 THE FOLLOWING: •I CEIRIFY T/ N�"'PEPFOAMANCIE OF THE W01'K FOA WHICH TMS PERMR IB IBBUEO,1 SHALL EMPLOY ET:fleONS SUBJECT TO WORKMAN'S COMPFN{ATION UWS OF CALIFORNIA.' MV T 2/HOUM IN ADVANCE FOR ALL REQUIRED INS TONE ATT 12001 4693422 COMPLETE DRAWING AT LOWEq AREA FO/�//1�,/1/.J) 7Rla_ U \L(LI/ �C D.I. O �Q PLOT PLAN ID—t.So.i.l Bo.N 'Ie 1 1.NAMES OF 8TREETB OR ROADS NEAREST TO OR BOU INO THE PROPERTY. 1.LOCATION OF IOV6E SEWAGE DISPOSAL SYSTEM OR ROI`O6ED 7.OUTLINE OF THE P OPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OVTLUNF.8 AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION Of WELLS W IIN RADIUS OF ONE HUNDRED FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PFOPERTY. ... . r Or PN SSSS.. i A, 2 0'a� 6i _ PU. LIG H tAeTH v� .. NVIRdWEN;A-Hi AL+H DIVltIn I �. A DEPMTMENT USE ONLY A.Plle.tleg - ..,. .sv- -- -_-.c.d wa-, ^.s�-•,,,;,,,.:,f ...Pt.B Br by De•lnmlbn ImP+eG BY - Y t Ort. ` cemmex.: :r a J Io i/ c/su J0 CYcr s E LI p g A (u � Sa..•,+' y �L.wP a1" :5-7 ACCOUNTING ONLY: JUDO FACT PE CODES FEE INTO AMOUNT REMITTED SMASH RECEIVED by DATE PSAMITJSSAVICt REQUEST NtIM86L INVoICE -3 0/ o3173a T-A19 ID 7 03/733 ,J Pub.Health SEN.-Enviro.173(3/96) I I ,ff