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} <br /> a <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> E SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 46$-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I TEAR FROM BATE ISSUER <br /> (C&IfpISF� fB TripRe&I�) ii <br /> . APPLtCATION IS HERE BY MADE TO THE SAN JOAGI M COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOFW DESCRIBED,TIES APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> '4 JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER @-1 115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> {. JOB ADORESS/ORAAPNIi CITY [�� '�� PARCEL S12EIAPN/ Q <br /> OWNER'S NAME i`• �A •_`�v1�F. .t4) -v�.It:1 :S�'Y.1.— ADDRESS G)—1 'I,��f(�('.{",t y y.}y� <br /> { Au <br /> CONTRACTOR 7 -�/.tt S - ADORERS I[f W&kSw Pu1-Lh l�'J Ucs PHONE. <br /> �"s� y� y, 1 <br /> E PLUS CONTRACTOR_V �"+ �.1:1 ti}' -- _ADDRESS ac•—s1I loci vI`1 k UCJ �l�i rCJ� PHONE II T 3� .16 5— <br /> �r <br /> TYPE OF WELL/PIMP: NEW WELL ❑ REPLACEMENT WELL )Rr—NTORING WELL 83 ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR © CROSS-CONNECT REPAIR i': ❑ VAPOR EXTRACTION WELL 1 J <br /> ❑New❑RwP.k H.P. DEPTH RUMP SET FT. 3'�, FmBT WATER LEVEL O <br /> (TYPE Of PUMP! ❑ OUTOF-SERVICE WELL ❑ GEOPHYSICAL WELL 1 �# ❑ SOIL BORING a <br /> ❑DESTRUCTION: ,{ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION&Cl BOTTOM A <br /> " �f k <br /> ❑ INDUSTRIAL OPEN EAOM A.Of WELL EXCAVATION _ V�p—�,•, DIA.OF CONDUCTOR CASING <br /> i�/� 0 <br /> ❑ DOMEBTscmRIVATE ❑GRAVEL PAcxiwE TYPE OF CASINO/STEEL/PVC V f.. DIA.OF WELL CASING Lit O <br /> f ❑ PUBLIC/MUNICIPAL ❑OFMaN DEPTH OF GROUT SEAL t �� SPECIMATION <br /> 1 13IRRIGATIONIAG �THER GROUT SEAL INSTALLED BY %M ti iL �i GROUT ARANO NAME C2LY��t 'f IW1.F� E <br /> k jay c <br /> 4 MONTORRING GROUT SEAL PRIMPED: l Yr ❑Ne :� CONCRETE PEDESTAL SY OWLLER:❑Y. pw S <br /> 3 s ��'� LOMING CHESTER BOXISTOVE PIPE s <br /> AIR X.DEPTH <br /> PROPOSED CONSTRUCTIDNIORILUPW METHOD, MUD ROTARY AIR ROTARY AUGER OTHER <br /> I MMSY CERTIFY THAT 114AVE PREPARED THIS APPLICATION AND THAT THE WOFK WILL BE DONE M ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND I <br /> REGULATIONS OF THE SAN JOAOUBM COUNTY. HOME OWNER OR LICENSED AGEHT'S.SaONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERT017MANCE OF THE WORK FGR WHICH r <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS O USJECT TO WORKMAN'S COMPtlMSAT10N LAWS OF CALIFOIMIIA.' CONTRACTOR'S HRIHO OR SUBCONTRACTING SIGNATURE CERFIFFES -� <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PEFF0 MAME OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORgMAN'&COMMSATRON LAWS OF t <br /> CALIFORNIA.' THE APPLICANT MIST CALL 24 HOURS IN ADVANCE FOR ALL REOUIIIWT IXSF--FlyECTTONS AT 120&1 4p,7875. COMPLETE DRAWING AT LOWER AREA PROVIDED. A 6 <br /> aw"d X Tlth V l�,�V}�.�. -(^I�YI.0. [/•--� Date I I 1 i_f <br /> ROT PLAN Ntaw to$e.M Sable 'to <br /> r- 7. NAMES Of STREETS OR ROADS?LEAFIEST TO OR BGUNOM THE PROPERTY• ;. LOCATK7M Of IgUBE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.ONMD DIMENSIONS AND NORTH DIRECTION. �I EXPANSION OF SEWAGE DOSPOSAL SYSTEMS. <br /> 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXOMNG AND PROPOSED S. LOCATION OF WELLS WTHIM RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALLS. ON THE PROPERTY OR ADJOINIID PROPERTY, <br /> DEPARTMENT USE ONLY iiL <br /> r' <br /> ' D. <br /> Avollaetlen Aeaepled 13 I . <br /> Data <br /> Rme ltyaaetlen BY Data <br /> G—A Imeeet on By !6 <br /> [ Dat• <br /> Ow.vuetbe tnaeectlan BIr�,I <br /> �, Cetwtna+t.' <br /> ACS <br /> ACCOUNTMO ONLY: <br /> NDS Fh <br /> PE CODE& FEE INFO AµOUMT AFTMTTED CHEC ASN RECEIVED■Y DATE It P9^gr11TlSWMCE REDUE&T NWSER INVOICE <br /> X180 <br /> I` <br /> Pub 4Balth Serv.-ERYiro.173(7197) ! _ g <br />