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APPLICATION FOR WELLJPUMP.jPERM[T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> . •v <br /> ENVIRONMENTAL HEALTH DMSIW <br /> 304 EAST WEBER AVENUE, STOCKTON, CA <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Camplefs Im <br /> APPLICATION 09 HERE BY MADE TO THE CAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT AmfOR INSTALL THE WORK DESCRIBED.TIPS APPLICATION IS MADE*4 COMPLIANCE WITH SAN <br /> JOAQUIN COUNTYDEVELOPMENT vrrt&cMAPTeR 9-1115.3 AND THE STANDARDS OF§AN JOAQUIN COUNry Pt,50�"EALTH SERVICES.ENVIRONMENTAL HEALTH OMMO <br /> M <br /> JOB ADJL�- rnQ a PARCEL SlWAPMr C <br /> OWNER'S NAME r ADORE:I;a 4fd?c---5 PHO ME I <br /> compAcTom-AADDRESS ili&j�neLk 1�—yas I[,A 'Aw L4-1 00z Lz�; w, 46 /JOG <br /> BUB CONTRACTOR ADDRESS 5Y6 UCIV PmNf r <br /> TV"OF VVELLMUMPI 0 HEW WELL 0 FmnAcmurr WELL wTOP,INO WELL R OTHER <br /> 0 INSTALLATION (3 WELL SYSTEM REPAIR 0 CA088-CONNICTFMPAtR I 0 VAPOR EXTRACTION WELL I <br /> 0 M.13 P.Pk H.P. of""PUMP SET Fr. PIRO.WATER LEVET. a <br /> (TYPE OF PUMM <br /> 0 ow-ar-earAcE WELL 0 GEOPHYSICAL WELL 0 ❑ BOIL ROMIG <br /> C— CLA02: it <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION$ ib A <br /> ❑ wwwrntAt ❑OOME9rtICJPR[VATZ OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO 0 <br /> 2-di'tAvEL FAcKmar: Type or.CAMNOISFEELIF6 DIA.OF WELL CASINO <br /> 0 <br /> ❑ M <br /> PUSIJCUWIPAL 0mvEM DEPTH OF GROUT SEAL Alr-h 9 SPECIMATION R i <br /> 0 1 ATIONIAG Ootmm GROUT SEAL INSTALLED BY ;11-f— anouT BRAND NAME E <br /> P-f-MITORING *muT SEAL PUMPED. 0 Y. ON. ii CONCRETE PEDESTAL BVDRILLER;0Y. bme <br /> APPROX.DEPTH LOCKING CHEWER ROXIOTOVE PIPE <br /> PROPOSED ClDN@TRUCnONfOPGWKU METHOD: MUD ROTARY AIR ROTARY AUGER CABLE VIL OTHER <br /> I HE-WRY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE wrim am•jcAcUfM"COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> nFOULATION15 OF THE SAN JOAQUIN COUNTY. MOL41E OWNER OR LICENSED AGENT'S SIGNATURE CER WMS THE POULOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR YAM" <br /> THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WOOMMAW&COMPENSATION LAWS OF CAUFOi"A.- CONTRACTOR'S HMNO OR BUS-CONTIRACTMO SIGNATURE CERTIFIES <br /> THE FOLLOWING- 'I CERTIFY THAT 04 THE PERFORMANCE Of THE WORK MR WHICH T"PfftMtr 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO Wall AN'S COMPENSATION LAWS OF <br /> CAUFOIMA.' rms s"4wjcApirj!!,W CALL!jgjW IN ADVANCE FOR ALL FMOUIRM IN VHM )1 ,�422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Skrwd X Ti"s '7-zZ48 <br /> i I <br /> PLOT PLAN f0vow to Saoial Saols to <br /> I. MAMfEl OF 9TfWFT5 OR ROAD$NEAREST TO OR BOUNDING THE PROPERTY. II 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM an PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.O"10 DIMt-MMONG AND NORM DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTUMFG AND LOCATION OF ALL FX18TINO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS of ONE MINDIWO FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJC*MM PROPERTY. <br /> a <br /> .......... .................. <br /> .......... .......... <br /> ------------- <br /> ifA? ................... ....... ...... ........ <br /> 0111 &IIII,Use ONLY <br /> A0,ftellan A4qseWWvd BY <br /> 01-A MwaeeHan BY By Dato <br /> O-qn.tfan Impeclion 84�-- j <br /> co-r�de! fA L4 L(J--L it <br /> 4- <br /> <A �-=Eii <br /> ACCOUNTING ONLY: AID# PAC# <br /> PE COOLS FIEEtNFQ I 3e==TTIED_ CNIECKNICAll" RLCPlqg-lj DATE IJ PERMIT/serfics REQUEST MUMIllan INVOICE <br /> er7 <br /> 1 67 2 --E <br /> :31.h Halth qa"--Prrvirn. 171!11971 <br />