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APPLICATION FOR WELLJPUMP PERMIT <br /> ' SAN JOAI]UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O. BOX 388. 304 EAST WEBER AVENUE, STOCKTON, CA 9S201C 0 <br /> (2091 469,Wfl py <br /> NON-REFUNDABLE PERMCC <br /> i <br /> 1ON IS HERE B'f),IALJE TO THE SAN JOAOUIN COUNTY FOR A PETIIMIT TQ CONSTRUCT ANMR INSTALL.THE VVIORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> im�COUNTY DEVELOPMENT TRLE.CHAPTER 9-11 J1�S 3 AND THE GTANOAROS OF SAN JOAQUIN COUNTY PU`BUIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> PARCEL WMAPN! .."IJ i IG L� Z <br /> U$ADORESSIOR APN, �-V ``{{ C•r I fO� [ 7 <br /> �S NAME, C"7 �4. \ I? LK"X" �)Lj ADDRESS. a1 D S h-FCq aLl�� C T -L-c� _ _ PHONE it <br /> TW�7aR 1j�1cnY �rt�lic� ADOREBB_ PQ Sax 33rD Q;J�� . L'C' ac -`i P40HHEE0 3 `+-`��� <br /> CONTRACTOR AL)ORESS LICJ PHONE <br /> _OF WELLIPI-IMP I� NfW WALL ❑ REPLACEMENT WELL_ ® MONITORING WELL f�W'��,R�W`I C} ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL.SYSTEM REPAIR ❑ cmoa9.CONNECT RfPwIR ❑ VAPOR EXTRACTION WELL l J <br /> ❑N—❑R4aM H P DEPTH PUMP SET FT FlRST WATER LEVEL a <br /> OF PUMP) <br /> ❑ OUT-0E-aETtVICE WELL ❑ aEOPHy=AL WELL.f ® SOIL&ORtNO I <br /> STFMkC71ON s <br /> ! b£O USE TYPE OF WELL GUM;TAUCTiON iPEC1LIG ATiO Ni <br /> L,a SN1OUSTI4AL ❑OPESI BOTTOM -7 OIA OF WEI..L EXCAVATION ZS 1 A"'1 DIA OF CONDUCTOR CASING Ij� D <br /> DOMESTICJPMVATE ®GRAVEL PAC%184E G I Z- TYPE OF CAStNO/STMJPNC_�� la ✓ - OIA OF WELL CASING `4 D <br /> PUSUC/MUNICIPAL ❑DPSVEN DEPTH OF GROUT SEAL iS 4'"�4 SPECIF#CAT10N <br />} MMOATIQNIAG ❑OTHER GROUT SEAL WSTALLED BY T d L�- x..11 GROUT BRAND NAME ��-'�� A�.YY".-^rY E <br /> Mo NCTORING ORO UT SELL PUMPED ❑Yr �13. CONCPZT-E PEDESTAL.BYDWLLER_❑Y- ON. S <br /> t <br /> IL OFTTH Z S-�tw LOOCMG CHESTER 8GXlSTDVE >rPE 5 <br /> PO iFD CONI Ij%c-nONtD1OLjJNQ METHOD- MUD ROTARY AIR ROTARY AUGER \ CABLE OTHER <br /> CERTIFY THAT 1 HAVE"REPARENO WWI <br /> D THIS APPLICATION ATHAT THE WORK WILL BE DONE IN ACCORDANCE WH ITSAN JOAQUIN COUNTY OPUINANCES 6-rATE LAWS AND RULES AND <br /> 1 "OF THE SAN 30AOUTN COUT 7Y HOME OWNEPT <br /> ER OR LICENSED AGT S SIGNATURE CERTIRES Tv,* <br /> FOLLOWTNO 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> IT 36 ISSUED I SHALL NOT EMPLOY PERSONS SUBJECTTO WOR"AN S COMPSUZATIOM LAWS OF CAUFORNIA. CONTRACTOR 8 HIRING OR SUB-CONTRACTING 6K3NATvRE CzDFMAES <br /> LLOWING I CERTIFY THAT IN THE PERFOPMANCZ OF THE WORK FOR WHICH THIS P9WTI IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN i CO#APM6ATIOM LAWS OF <br /> r'AUFORMA_ T}IF APP6C MLW G-JUL M !M ADVANCE FOR ALL AEOUIRED"tlr*CT)Op"AT M0.61 44s-7423 COMPLETE DRAWING AT LOWER AREA PfO VFDED <br /> cam - 3 z`I-T� <br /> s oaea <br /> ►LOT PLAN @raw to Ba�1+1 6.c.1. to <br /> NAIy{E$�F BTR{ TS OR fIOAIIS HEJCRE6T TO OR HC7UHORIG TFFE FROPERT'f 4 LOCATION OF HOUSE SEWAGE CISPO$AL SYSTEM OR PROPOSED <br /> UTUNE OF THE PROPERTY GLVIIJO DIMENSIONS AND NORTH DIRECTION EJCPAN$ION OF SEWAGE DISPOSAL SYSTEMS <br /> MENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED 6 LOCATION OF WELLS WITHIN RADIUS.OF ONE HUNDRED FIFTY FT <br /> RES INCLUDING COVEREb AFTAS SUCH AS PATIOS DRIVEWAYS AND WALYS ON THE PROPERTY OR ADJOINING PROPERTY <br /> e <br /> f MAP ON BACK <br /> l <br />.1 <br /> I <br /> tad <br /> DErAR TMENT USE OMLY <br /> R AeoaeBy <br /> ..� Sy bate Punv Irmo -c an BY Ort• <br /> S! prtr <br /> Irrvaa�^ <br /> Sy <br /> UNTIMa ONLT AA30 FACS <br />!� LME Comm FEW INFO AMOUNT PC06W TED CHBCKSICMN RECSr4W sY DATE REDUEiT NU 4AMER INVOICE <br /> 67, �5d 1 <br />