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I1.e0 AHalih � APPLICATION FOR WELLIPUMP PERMIT <br /> :cl 1 r Y;/ _ dAN JOADIUNTY PUBLIC HEALTH SERVICks <br /> "J EN • <br /> N�✓lqr :NSA.FL V# INENTAL HEALTH DIVISION <br /> AlY II P D BOX 395, 445 N.SAN JOAQUIN ST.,STOCKTON,CA 95201388 <br /> (209) 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED <br /> IComphM In Elplklb) <br /> APPLICATION IS HERE SY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW.DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WIT"SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS�TIF BAN JOAQUIN COUNTY PURUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOBADOBESBpNAPNI So,ITII r C0 / ---S-F/tEN/ `CITY PARCEL SIMM N <br /> JWA I shDDIE C G <br /> OWNER'S NAME_ T / / O •V N/PITT M CNEv1AA DOREsa P� 1TO�C ,� !30 LQO/ PHONE 1 s - <br /> ccgr�, E E� 20-) �C ChA�n� OC/ 1 2- <br /> CONTRACTOR ADORERS FHONFI <br /> "a CONTRACTOR ADDRESS UCI PHONE# <br /> "HOF WEW%IMP: ❑NEWWEU- ❑REPLACEMENT WELL ❑MONROmNO WELLI ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL I J <br /> ❑Nex❑RG" H.P. DEPTH PUMP SET_R. FIRST WATER LEVEL O <br /> (TYPE OF PUMfl <br /> O/ rll ❑OV-OF6ERRE WLL ❑GEOPHYSICAL WELL ❑ SOIL OgO <br /> L./ESTRUCTIDN: be llm { 17 P V —�TCK B <br /> SA P/P I d- tit f— If 1/ 12)/y"vat <br /> q(y�ANq/�V(�/n� <br /> INTENDED TYPE OF WELL TAX OF WFU.E EXCAVATION <br /> 1 JL1 F / _ U A <br /> ❑INDUeTmAL 11 OPEN BOTTOM MA.OF WELL E%cgVpTION L pA.Of CONON/CTOR CAmNO D � <br /> ❑COMESTIC/RUVATE ❑OMVEL PA*TARRE TYPE OF CAGING/STEELTVC MA.OF WELL CASINO O <br /> ❑PIBLICMUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R L <br /> ❑mMGAT10N/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MON'ONNG SNOUT SEAL PUMPED:11Y-- [IN. CONCRfTEPEDESTALBYDRILLEII:DY. ❑N. S <br /> APPRO%.DEPTH LOCKING CHESTER BOXBfOVE PIPE S 7 <br /> PROPOSES CONSTRUCTIONNWWNO METHOD: MUD ROTARY AIR POTARY pUOd CABLE OTHERG <br /> I HEUEBY CLARIFY THAT 1 HAVE PREPARED THIS AFRICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND MILE8 AND l <br /> REGULATIONS OFTHFBANJOAGUINCOUNTY. HOME OWNER OR UCENSEO AGENT'BmGNATURE CERTIFIES THE FOLLOWING:'I CERNH YTHAT M THE PERFORMANCE OF THE WORK MR YMICH . <br /> THIS PERMIT IS ISSUED,I SHALL HOT EMPDY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA:CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIER <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMKOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> 9IGM PENIA' T C RI LL}I LIq W PI,ASVAHCF MR ALL REOU:EO INFPECD p AT MO81 NBJ828.COMPERE DRAWING AT LOWER AREA PROVIDESTRI . <br /> , <br /> E/./L,(,Iw, KOT MN 10'—"B l awls U rI J'Te <br /> L NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. L LOCATION OF HOUSE SD "E DISPOSAL SYSTEM OR PROPOSED ' <br /> 3. <br /> OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DMW BK ECTION. E%PANBIGH OF SEWAGE DISSYSTEMS. IT <br /> ].DIMENSIONED OUTLINES AND LOCATION OF ALL EXISNNG AND PROPOSED S. LOCATION OF WFLLB WITHIN RADIUS OF ONE HUNDRED FIFTY FR. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DMVFNAYS,AND WALKS. ON THE PROPERTY OR ADJOINING MKR1Y. T <br /> pf <br /> PA CFnA <br /> R <br /> PIf 1tT <br /> A�APR18 19gS <br /> Cn,.,YpNMEN�i6q fq ITgv '... <br /> SCCVtI-C ��Ai Gw <br /> DEPARTMENT USE ONLY ���� '����, ,��,��,P ���,, <br /> APE"."n Aecpmtl 81�� Al%ll D.l. L-�J�]_Nw <br /> Gram In.wwUnn Rr mT. P p IwPwtton aY l D.1. <br /> Uwo-v+Tbn lwP.an M D.T. �F oZo S <br /> AC:..T.G ONLY: AIXI FACI <br /> PF CODES FEE INFO AMOUNT REMITTED X&EDICAUTH RECEIVED BY DATE PFRMITIBdVICE REOUFIT NONNI INVOICE <br /> !?3V& 4S / <br />