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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE . <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAUUIN ST., STOCKTON, CA 95201-388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) APPLICATIONIS <br /> HE <br /> T ANDIOR <br /> NSTALL T <br /> JOA UUIN (COUNTY OEVELOPMEM TRIE, CHAS R 9-111/5.{- ND THE SiRANDAROB O SANIT TO CJOAQUIN CIOUNTV FUBUC HEA LH SERVICES,HENNRONMENTAL HEALTH IDIVISION.COMPLIANCE WITH SAN <br /> JOB ADDRESS/OR Al 115 3 D �,,1 EI G I� I M It te Cl Moc omA /, In PARCEL SIZE/All <br /> �I( I J �j , 1 L I� I7 d PHONE <br /> OWNER'S NAME I11lAq <br /> 5r'1././/���1 - / // ���� ADDRESS [�, �(' 3 ��_G _7 <br /> Srt I1 / rIJ .l( TTA ! TZ41 LL921 ADDRE6617 /0/llii Y? ?. �s� ICN PHONE NT <br /> CONTRACTOR TLl f ! . . . ,u� I, . n . , / yy1 II��L� r20�r� <br /> ��fnl/afib�-I � ADDREss23/OFr CJJ/L/Wy SIVC/ • /L (IICN J 2Z PHGNEA.Y( S�.ZZ / Z <br /> SUB cow on rte/ - <br /> TYPE OF WELVPUMP: ❑ NEWWELL ❑ REPLACEMENT WELL LJ MONITORING WELL N1�rL� ❑ OTHER <br /> [3 INSTALLATION ❑ WELL SyU EM REPAIR [ICROS620NNELT REPAIR ❑ VAPOfl EMRACTION WELLY 0 \ <br /> ❑ New ❑ Rall HAI DEPTH PUMP 6ET_Ff. FIRST WATER LEVEL <br /> RYPE OF PUMP( ❑ SOIL BORING B <br /> 1/1I, A ,� / +❑` ,D�UAf-0F6EflVICEWELL `❑ G/E/O/PHV\1SICALWELL ♦ <br /> OESTRUCTI N <br /> Over <br /> lllfl �I MI /��{ I�f UJI1 \ X17 /NLnUH 1 � ± F�11 .�/'/� ��IA4' })1771UW IU _ f lHjoq. E • <br /> C NTP TO PE R TION - X75 A <br /> INTENDED USE TYPE OF WELL o D <br /> ❑ INDUBTWAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION o � � Al' DIA. OF CONDUCTOR CASING <br /> DDUsTEGC/PPIVATE ❑ GRAVEL PACK/SRE TYPE OF CASINGISTEELA'VC c UG DIA. OF WELL CASING cam. '/ ll �- D <br /> [3 <br /> ❑ WBUC/MUNICIPAL ❑ DRIVEN DEPTH OF GIROIfT SEAL — T� SPECIFICATION <br /> ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED ff lCv'i L, � I -e I GROUT BRAND NAME E <br /> ❑ rye S <br /> ❑ MONITORING 1 GROUT SEAL PRIMPED: ❑ V� ❑ No CONCRETE PEDESTAL BY DRILLER: Vs S <br /> wall DEPT" / 6 / LOCKING CHESTER BENE VE PIP�E// <br /> PROPOSED CONBTIIIGTIONIDW W NQ METHOD: MUD ROTARY <br /> AIR ROTARY�j= AUGER,}_ CABLE OTHER (e <br /> WSAND RULES AND <br /> REGUTATON6 OFTHE SAN JOAOUINOUNTY.SXOMEOWNEfl ORLLLENSEDA EM'S jr <br /> TXENFOLIOWINGANI CERRFV THAT IN THEDPERFORMANCETOFITHE WOW FOP MICH \ <br /> THIS PEPMR16168UED, I6HP31 NOT EMROV PERSON66UBJECT TO WOPKMAN'8 COM14NSATON LAWB OF CALLFORNIA.' COMRALTOR'B HIRINGOR <br /> TO O{ "'& CO SIGNATURE CERTIFIES <br /> TXE FOLLOWING: ' I CERTIFY THAT IN THE PEflFORIAANCE OF THE WOW( FOR WHICH TRIS PERMIT I618SUED. 1 SHALL EMPLOY PEIRSON6 SUBJECT TO ER AM AN'B VIDEO. BATON LAWS OF <br /> CAl1FORNIA.' TXE APPLICANT MUBT C 24 LpUR61N ADVANCE FOR ALL REOUPED INEPECTIOMt AT 12OBI4BEs42D. COMPLETE DRAWING AT LOWER AREA PROVIDED. ( <br /> /^� TVY1 FJ,J1" nne �rolrr -(' SU (Jr Y'YtrS OYData <br /> oAl sloroa x �4 klM/11.P, - - <br /> PLOT PIAN (Draw to Sc.lel 6eaM <br /> 4. LOCATION OF HOUSE SEWAGE DISPOSAL BV6TEM OR PROPOSED <br /> 1 . NAMES OF STREETS Ofl ROADS NEAREST TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2. OIRUNE OF TXE PROPERTY. GIVING OIMENSION6 PND NORTH DIRECTION. 0. LOCATION OF WELLS VNTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> 3. DIMENSIONED OUTUNE6 ANO LOCATION OF ALL EXISTING AND PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY. <br /> STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS. AND WALKS. <br /> _ f\ITALnEFIU-1 <br /> DEPARTMENT WE ONLYOF <br /> /� �� #15 <br /> ` <br /> Date or J a.. <br /> Application Aewte <br /> otl BY <br /> Dote Pump Impaction By. <br /> Groot Inapeellen By <br /> Date <br /> Datru ion ImPatlon B <br /> Comm <br /> _ <br /> "COUNTING ONLY: <br /> AIM FPL/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC"ICASH RIDE BY DATE P ITIS�CE MUUUT NUMBER INVOICE <br /> I <br />` C (o Fy <br />