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•PPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 h <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DIKE ISSUED <br /> ICNmp1EtE M Tyla0cEld <br /> APPLICATION IS 14FM BY MADE TO THE BAN JOAMIN COUNTY FOR A PEMIT TO CONSTRUCT ANCHOR INSTALL THE WOW DESCRIBED.THIS APPLICATRIN 18 MADE IN COMPLIANCE WITH BAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY MOM HEALTH SEIMCES,ENVIRONMENTAL HEALTH DIVISION. <br /> r �C,�_�, <br /> (.l✓� Irf� cnry STOC,�-Taf� PARCEL SIZEIAPN/ 3 <br /> JOB AODREBSroRpA�PN�/•�r5'�� / r� /^ f1 �C����+p G <br /> 1 tT'�lT-4(Z- V H's r F-t�_ LCL/, ADDRESS 7 J� s �T I� 1 rte- sr PNONE. '✓DZ(' <br /> OWNER NAME 11 j1 :Sq I�A/� �D <br /> �J�COMPACTOR v\�J� �� r _� �0_ Or-�� avv _uc1L 3 .133/ oNE2 <br /> Sl18 COMMCTORSTT1�iHA^ 1 41.PLY1 FfT_RO��tJ C.! IJ�G/ AADonEee2f+W1-rWAI^1r91Z\VE LACI, ILZp PHONE IZ'9 -RIZ <br /> TYPE OF WELI/R1MP: ❑ NEW WELL ❑ REPLACEMENT WELL IJ�MONRONNO WELL I Z) ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR r(Lll CACS8 ONNECT REPAIR ❑ VAPOR E%TRACTION WELL F J <br /> DEPTH RUMP BET-- <br /> FT. FIRST WATER LEVEL 0 <br /> 11 Nen❑Peeelr H.P. <br /> ITYFEOF RUMP) ❑ OM-0E-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL SOPNO S <br /> ❑DESTRUCTION: <br /> A <br /> INTENDED USE TYPE DF WELL CONSTPIICTION SPECIFICATIONS � AJ 85/p, W <br /> ❑ INMBTmnI ❑OPEN BOTTOM OIA.OF WELL EXCAVATION tACYT DIA.OF CONDUCTOR CASINO <br /> ❑ DIA.OF WELL CASINO 2.11 0 <br /> CCMEBTICS`HIVATE ❑GRAVEL PACK/SIZE TYPE OF CABINOMTEE <br /> ❑ RUBLICIMUNICMAL ❑DPVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> E❑y ImYGATION/AG ❑OTHER GROUT SEAL INSTALLED BY "ROM BRAND NAME E <br /> LEN MONITORING��I ��� fj [ T1 ( GROUT BEAL PUMPEO: 11 Y- 11 N- CONCRETE PEDESTAL BY DPLLER:❑Yr Npe 5 <br /> 7 Z•"�—� OV �^WFI'V� LOCKING CHESTER SOXISTOVE RPE / - 5 <br /> APPRO%.DFPIH ``// <br /> PROPOSED CONSTRIICTIONroAWNO METH O: MUD ROTARY AIR ROT AIN AUGER CABLE OTHER_ <br /> 1 HEREBY CEATIFY THAT I HAW PREPARE"THIS APPMATION AND THAT THE WORK WILL BE DONE M ACCOMANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUM COUNTY. HOME OWNER OR LICENSED AOENT'S 910MATUM CERTIFIES THE FOLLOWING!'I CERTIFY THAT M THE RRTOfHn/ANGE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,1 SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWN OF CALIFORNIA.- CONTRACTOR'S MAIM OR SUSCONTRACTMG SIGNATURE CERTIFIES <br /> THE FOU 10: '1 CERTIFY THAT IN TIE PERFORMANCE OF THE WORK FOR WHICH THIN PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WCRDIAN'S COMPENSATION LAWS OF <br /> CAUFO A.' THE APR/.I/,L- R MUST GALL 2A HOURS IN ADVANCE FOR ALL RFOURED INpEP�ECTfM`NE�AT 1�3/N1I,A.�tl�- 223.. C+OMMP ETE DRAWING AT ROWER AREA PRONDED. <br /> mprJX IP i./I \��� TIIIB �E-WW` I' YfTI`rT` lJ T/Y� On. I Z4�� <br /> T ^ <br /> 0.0T"mDrew to ea�al <br /> 1. NAMES STREETS OR MADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DIBPOBAL SYSTEM OR PIIOIOBED <br /> 2. OUTLINE OF THE PROPERTY,ONNIO DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2. DIMENSIONED OUTUNFB AND LOCATION OF ALL EXISTING ANO PROPOSED S. LOCATION OF WELLS WTTMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SINN AS PATIOS,DRIVEWAYS,AM WALKS. ON THE PROPERTY OR AOIOINMO PROPERTY. <br /> DEPMTMENT USE ONLY <br /> nwne.11en AwwRea er rJ A <br /> /G ne a Ima«Hen Br Dele <br /> GroU MnP«Ibn BI <br /> Oeeawtlen Irwn«H er / <br /> �7 <br /> ^• 4, / Cr r <br /> !� %`\JV <br /> (� USS 2 <br /> AccDLMnNG ONLY: <br /> AIDS MCI <br /> IE CODER FEE INFO AMOUNT P TIED CNECoK/CMN R C VEO■Y DSL I �� .3 j C E REGVEIT MUMBBI INVOICE <br /> Z 0 L �� M 2 12 <br /> Pub Health Se W.-Enviro.173(1197) <br />