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PLICATION FOR WELUPUMP PERM <br /> SAN kAQUIN <br /> COUNTY PUBLIC HEALTH SESCES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 1 <br /> XON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> A �p�j <br /> 1 (CRmpIRtR M TiOlketR) <br /> I'IZICATION 18 HERE BY MADE TO THE BAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS A KATION 18 MADE IN COMPLIANCE WITH$At <br /> JOAQUIN COUNTY DEVELOPMENT TtTL2,CCHAPTE O-11 AND TFIE fT ATOS Of SAN JOAQUIN C)1UNTV PUBLIC HEALTH BERVICEB,ENVI HEALTH DIVISION. <br /> JOB ADOREBSMst f <br /> R 160-nb/ <br /> ' _P L Blzf/APNF_l9 f <br /> 1 OWNER'S NAME <br /> yyCC�� ADOW S S I PONE <br /> CONTRACTOR Y{iTRU Mp`1^ <br /> ', <br /> AOd1EBS I�"� _lk1 <br /> INTONE I <br /> BVB CONTRACTOR ADOIIESS LK:/ M/ONE/ <br /> TYPE OF WELL/PVMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MOMTOPIIIG WELL/ OTHE <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ C"08t1-COWACT REPAIR ❑ VAPOR EXTRACTION WELL 1 <br /> 1 ❑04—❑Rep.h H.P. DEPTH NMP BET FF, FIRST WATER LEVEL 0 <br /> (TYPE OF MMPI <br /> 11OVT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 1 Ly BOIL go <br /> ❑DESTRUCTION: (J GG `'-i-=�"`• <br /> INTENDED USE TYPE OF W CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION OTA.OF CONDUCTOR CASINO 0 <br /> ❑ DOMESIICK"VATE ❑GRAVEL PACK1612E TYPE OF CASINO/BTEELJPVC DIA.OF WELL CARING 0 <br /> ❑ NBLIC/MUNICIrAL ❑DRIVEN DEPTH OF OnCUT 1 REAL I,�tg s,•P��/j3 SPECIFICATION R DATION/AG ❑OTHER GROUT REAL INSTALLED BY •Vr— ,r-,`—•` GROUT BRAND NAME E <br /> MONI IONNG ^ 1 GR OUT REAL PUMPED: ❑Yr 11NoCONCREPE PEDESTAL RY DRILLER:❑YM ❑Ne a <br /> APPROX.DEPTN _/L LOCKING CHEERRT/�!l SOX/STOVE P" s <br /> PROPOSED CONS TRUC TIO NIDRILUNG METHOD: MUD ROTARY AIR MOTARY_ J� AUOCR CABLE OTHER <br /> I H(g1RY CERIIFY TIIAT 1 HAVE PREPARED THIS APPLICATION AND THAI TIRE WORK WILL BE—DONE IN ACCORDANCE WITH RAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AN <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY, HOME OWNFR OR LICENSED AGENT'S SIGNATURE CERTIFIES TILE FOLLOWING:'1 CEMIFY THAT IN THE PfWORMANCE OF TIRE WOPK FOR WPIC <br /> 71118 PERMIT 18 ISSUED,I81/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB CONTRACTING SIGNATURE CERTTIFIE <br /> 1 TIRE FOLLOWING: 'I CERTIFY TIIAT IN TIRE PERFORMANCE OF THE WORK FOR WIIICFI THIS PRMPP IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS 0 <br /> CALIFO ' THE A C T MV CALL 24 HOURS IN ADVANCE FOR ALL REOU111ED INSPECTIONS AT("014004422. COMPLETE DRAWING AT LOWER AREA PRO EO� <br /> RlS.rX d Tltle ��J(j-/f� Dele <br /> pIOT PLAN It),—le Reelot Seel. Pe <br /> i. NAMFR OF Smuts OR ROADS NEARFBT 10 OR ROUNDING THE PROPERTY, 4. LOCATION OF HOURS SEWAGE DISPOSAL SYSTEM OR PROP08ED <br /> 2. OUTLINE OF T11[PIOPRTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 7. DIMENRIONEO OVTUNES AND LOCATION OF ALL EXISTING AND P10PORE0 S. LOCATION OF WELLS WITPON RADIUS OF ONE HUNDRED FIFTY R. <br /> BIRUCtURF.S,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PFTOPERTY OR ADJOINING PROPERTY. <br /> : <br /> .; ....:... <br /> . .,. :.. . . ,.... ..� PAYMENT <br /> . . . .. <br /> R <br /> .i <br /> JUN .... <br /> 0..91997:.. .. . . •< . <br /> i <br /> JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRpNMENTAL HEALTH DIVISION' <br />