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APPLICATION FOR WELLIPUMP PERMIT <br />' SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O E3OX S88,SO4 EAST WE:SE R AVENUE,STOCKTON.CA 95201388 <br /> (208)468 3420 <br /> MOR REFUND BLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> j 1CBmplBt6 M Tlk&olol <br /> AP1'LICA7ION IS HERE BY MADE TO THE BAN JOAQUIN CGUN7Y FOR A PERMIT TO CONSTRUCT ANDJOR INSTALL THE WORL DEPCRBED THIS APPLICATION 1E MADE IN COMPUANCE WITH CAN <br /> JOAOUIN COUNTY OFVELOPMENT TITLE CHAPTER 9 1115 3 AND THE STANDARDS OF SAN JOAOIRN COUNTY PUBLIC HEALTH SERVICES ENNRONMfHTAL HEALTH DIVISION <br /> JOB ADOEESSIOR APN# D dj2 CITY .E </z7--4-7671'/1 PARCEL BREIAPNO lam-7 W Z&l <br /> OWNER NAME �3f-NG t} S/�+y ,T ADDRESS _PHONEI q-L11�2!; <br /> CONTRACTOR lz ADOMBTB JL^^^a�TTT k!6 'A �1 5Z _UCF Nr RHONE F6z2gi.3alr:�,s <br /> OW!2tgo..tG! ADDRESS ! 7 LICF MIOHE F��J - ' <br /> I y'y <br /> um of WELuwMP•. 1�HEW WELL ❑MR ACEMENT WELL ❑Moworma WELL• ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROso�oNNECT REPMR ❑VAI-0R EXtRACTION WILLI J <br /> 11N—❑ IF <br /> R .I, H P OEPFH PUMP SET FT FIRST WATER LEVTL O <br /> rt YPE OF nrMv]1 �-7❑OUT-0r BERVICE WELL ❑OEORIYBICAL WELL J ❑ SOIL BORNG B <br /> f26ESTRUCTION—0/",3 s_ l�lQ�:Ze-,. !J,- ,&--&l-ML4 ---_(P�T 0,- AJr J/ <br /> INTEHDEP EE TYr4 OOFW CONSTRUCTION SPECIFICADONS A <br /> ❑WDUOTRAL OPEN BOTTOM DIA OF WELL EXCAVATION-- �/ CIA Or CONOUCTOR CAMNO � n <br /> 1 ❑DOMEBTICMSVA7E ❑GRAVEL PACK(BIZf TYPE OF CASIHOM7lELRVC__. TSP CIA Of WELL CASINO <br /> I� / D <br /> ❑PUSLICAAVNICMAL ❑ONVEN DEPTH OF GROUT SEAL 1C]f SPECIFICATION R <br /> ❑MAIGATIOHAG ❑OTHER GROUT BEAL INS7AMF13 NY GROUT BRAND NAME �T E <br /> ❑MOWTOPOPM GROUT BEAL PUMPED ❑Y- EI N. CONCRETE PEDESTAL BY DRILLER[IV. ON. s <br /> 1 APFROX DEFT" LOCKING CHESTER sbk/StOVE APE s <br /> PROPOSED CONSTRUCTIOIUDRLURG METHOD MUO ROTARY ASI ROTARY AUGER CABII; OTHER <br /> 1 HFIFBY CERTIFY THAT I HAVE FIrEPA1ED TMB APPLICATION AND THAT THE WOES[WILL BE DONE IN ACCORDANCE MATH BAN JQAGUIN COUNTY ORDINANCES STATE LAWS AND h111E6 ANO <br /> REGULATION*OF THE BAN JOAOUOT COUNTY NOME OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THB PERMIT It ISSUED 1 SHALL NOT EMPLOY PERSONS SUBJTCT 70 WORIOMAN S COMP104/6471ON LAWS OF CALIFORNIA CONTRACTORS HIRING OR SU"ONTRACTWO SIGNATURE CERTIFIES <br /> 1 THE rOLLONTEIG I CERTIFY THAT OR T14E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN S COMANSARON LAWS OF <br /> CALIFOIWA./J/T)IE AFPUCAItT MU*T C S4 HOURIE IM ADV E FOR ALL REDuwta INFECTIONS 4E/170B14M-f4tf CGMR.EFE CMYVING A7 LOWER AREA PROVIDED <br /> T. <br /> ROT RAN EA.w IB SwN <br /> I NAMES OF STEESTS OR ROADS NEAREST TO OR BOUNDRTO THE PRIDP M 4 LOCATION OF HOUSE SEWAGE OIBPOBAL SYSTEMPM <br /> r4)9[0 <br /> OR PIOSED <br /> 1 3OUTLINE OF THE iNSIO <br /> OPERTY OPANO DIMENSIONS ANIO <br /> D NORTH DIrItCTN EXPANSION OF SEWAGE DISPOSAL SYSTEM@ <br /> s OIMENPDNED OUTUNFS AND LOCATION OF ALL EXISr000 AND PROPOSED B LOCATION OF WELLB WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br /> STRUCTURE$MLL43M COVERED AREAS SUCH AN PATIOS DRIVEWAYS AND WALKS ON THE PROPERTY OR AbJOINM P'ROPERrY <br /> li } <br /> v � <br /> 1 � , <br /> @ e f✓Or G�d�C!"1 <br /> 1 AWARTMENT USE ONLY <br /> APFB."yR As. Id By Dr. NRr� <br /> 1 ck A&w-1 Br D.t. Piny BIIPP.II.A By O.I. <br /> L:.n.wp.. w <br /> ACCOUNTING ONLY ANP FAC# <br /> FE COOEA FEE IDG AMOUNT REASTTED CHE ASH RECBvm■y DATE P@NNT/*tRVICE REQUEST NUMBER INVOICE <br /> 2klk <br />' Pub HoWth SBry Envlro 173(3196) <br />