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APPLICATION FOR WELL/PUMP PERMIT ' j i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 r (209) 458-3420 oq 17 — 0 NON-REFUNDABLE PERN1T EXPIRES 1 YEAR FROM DATE ISSUED Meme" he Trlp&4t.1 APPLICATION 48 HERE BY MADE TO THE SAN JOAOUM COUNTY FOR A PEF"rr TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IR MADE IN COMPLIANCE WITH,SAN JOAOUIN COUNTY DEVELOPMENT T�ITtE,CHAPTER 8.1116.3 AND THE STANDARDS OF BAN JOAOUIN cOU PUBLPC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADIMSSMR APN/ ( 6 N CITY PARCEL SI2E/APT1r OWNER'S NAME A0011ERS j PHONE r 44 CONTRACTOR O• PPDI+E'y`r��U RIJB CONTRACTOR AGGRESSLPC' PHONE i w ■ � nen � ..� DIM 2EAAi ❑ NEW MILL El REMACEMENT WELL Cl MONITORING WELL 0 0 OTHER )?06wALLATMN— ❑WELL:EYETLM-REPAII -❑� CROSE=CGNNECT VEL AIR — - - ❑-VAPOR EXTRACTION WELL r -- - - -- -y— ❑Now 13FW0611 N.P. - DEPTH PUMP 8ET Z IT. FEIST WATER LEp Tt YPE Of P11X1P1 i ❑ OVTOFIERVICE WELL ❑ GEOPHYMCAL WELL' ❑ SOILBORING g ❑OE STRUC TION: INTENDED USE TYPE OF WRI CONUXUCTION SPECIFlCA ONS A ❑ imxmRIAL ❑OPEN BOTTOM DIA-OF WELL EXCAVATION GPA.OF CONDUCTOR CASINO D ❑ OOMESTICIPRIVATE ❑GRAVEL PACK/BIZE TYPE OF CARPP413MTEEIIPVC DIA.OF WELL CASINO 0 ❑ PUELPCIMUIMCtPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ MN GATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAD NAME E ❑ MONTTORINO GROUT SEAL PWKI). ❑Yr [IN. CONCRETE PEDESTAL BY DRILLER;❑Y■. [IN. S APPROX.O>srN LOCKMG CHESTER BOX/STOVE PIPE S PROPOSED CONITRUCTIONMAILLPNO RAETHOD: MUD ROTARY AIR ROTARY AUGFA CABLE OTHER t HEREBY CERTIFY THAT t HAVE PREPARED TRPS APPUCATION AND THAT THE WOW WALL BE DONE W ACCORDANCE WITH SAN JOAOUIN COUNTY 0AINNANCEB.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUtN COUNTY. HOMIF OWN"OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:7 CERTIFY THAT M THE PERFORIdANCE OF THE WOfK FOR WHICIf TIME PERMIT to ISSUED,1 BHA NOT VAPLOY PERSONS SUBJECT TO WOROAAII'S COMPEIIEATION LAWS OF CAUFVO*A." CONTRACTOR'S 1"NG LIR BUB-CONTRACTING SIGNATURE CERTTFIEE THE FOLLLRMNO; '1 CEITT THAT M PERFORMANCE OF THE WORK FOR WHICH THIN PERMIT 1 .1 SHALL EMPLOY PERSONS SUBJECT TO WORIONAN'E CONN 016ATION LAWS OF CALAORMIA." UST HOURS IN ADVANCE FOR ALL REOUIR INQtCT10 �(20E1�4J"�4422, COUKETE DRAWING AT LOWER AREA PROVIDED, 8$0- X Ttft Y ,/ � DN■ PLOT RUIN ID+ow N$000)Sad■ 'N 1. NAME@ OR STP4ETB OR ROADS NEAREST TO OR BOUNDINO THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE OISPOEAL EYETEM on PPOPOBED 2. OUTLIK OF THE PROPERTY,OfVINO DM1EENSRONE AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOM EYSTEUE, 2. DWENSIONED O'V7LME8 ANO LOCATION OF ALL EXPtTOM AND PROPOSED E. LOCATION OF WELLS WITHIN MONS OF ONE HUNDRED FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATMI,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR Ab"INITM ROPERTY. y. �.. �. i. �..... .�.. : V' C i i- : i C ...,... .. .. .. ...... ... ..... .. :�f�WOW Q F • C■ ■ ' ..... .. .. ., .. v .. ........: .. .._. . ..p. ......... • . �� 8JWcclursn •