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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> i <br /> f ON-REFUNDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Camplalr Ire TFlplle$P$d <br /> APPLICATION IB HFRE BY MADE TO THE BAN JOAOUW cowry FOR A PERMIT TO CONSTRUCT AWMn INSTALL THE WOFK OESCRIBEO.THIS APPLICATION tR MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,C14AFITEER 9-1119.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, <br /> JOB AODRESSATA APR OO /j (-'(L-. ��p Ctry S L,- r� O}— PARCEL WZFJAPNI S A 4 <br />�. OWNER'S NAME /(// /C Lr �`'i—-- A/v AOORERB y �/yx c,.. <br /> y��� FTIGIaF r 9 i 3— <br /> COPFIRACTOF � �. G/SV S.S ADOIIEBB G r�/] 2 LICr_3223pp.S_ PHONE,23 -22 LS <br /> BLIb cnNTRAcrbn_�3W ti-Ek <br /> ADORERS Llcr PHONE r <br /> TYPE OF WELL/PUMP eNFW WELL ❑ REPLACEMENT WELL ❑ MONrLOIUNO WELL/ ❑ OTHER '1 <br /> ❑ INSTALLATION © WELL YRTEM MPAIR ❑ CROSS"CONNECT REPAIR J <br /> `J ❑ VAPOR ER LE E K]H WELL r <br /> I1 YPE OF PUMPI /y"7'1 Nm❑ M.P. OEP'fH PUMP BET IT- FIRST WATER LEVEL O <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL r ❑ BOIL a0rum B <br /> ❑eERTRUCTIbN: • <br /> INTENDED U$E TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �j _ DIA.OF CONDUCTOR CASINO O <br /> _j-_j�OOMESTMXRlVATE ,%TORAVFL PACKIBIZE TYPE OF CARINGlBTEELlPVC _ ..., DIA.OF WELL CASINO_- I(D O <br /> ❑ PUBLICIMUNFCIPAL ❑ONVEN DEPTH OF GROUT SEAL C70 srrCIF!CATION yjq k <br /> ❑ IIIRIOAT,ONlAO ❑OTHER GROUT SEAL INSTALLED BY GROUT POLAND NAME <br /> ❑ MONITORING GROUT SEAL PUMPF('P _ ❑N. CONCRETE PEDESTAL BY DRILL!3 <br /> o Y. DN. 5 <br /> APP„OIT,Pf"M __ LOCKING CHESTER BOKAITDVE POPE / S <br /> PROPOSED CON$TI,UCTIONm"tUNG METHOD: MUD ROTARY ABI ROTARY AUGER CABLE OTHER <br /> 1 HE9E6Y CERTIFY THAT!HAVE PREPARED THIS ATY`UCATPON AND THAT TINE WOW WILL SE DONE IN ACCORDANCE WITH RAN JOAOUIN COUNTY OnDINANCES,Sl ATE LAWS.AND RULER AND <br /> REGULATIONS OF THE SAN JOAOUFN COUNTY, HOME OWNER OR UCENSEO AGENT'S SIGNATURE CERTIFIES THE FOLLOMONG:'1 CERTIFY THAT IN THE P FRFOAMANCE OF TO IE WORK FOR WINCH <br /> 1141E PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMP'FNSATION LAWS OF CALFFORMA.- CONTRACTOR'"MT$NO OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CEITTIF Y THAT IN THE PERFORMANCE OF THE WOPK FOR WIIFCH TMS MMArr IS lSRVEO.I SHALL EMPLOY P4RSONS SUBJECT TO WORITMAN7 COMPENSATION LAWS OF <br /> CALIFOl'"A.' THF APPLICANT MUSY CALL 24 HOURS IN ADVANC[FOR ALL BEOUIBEn!N$P$'CTMN$AT 12"1 4".*422. COMPLETE DRAWING AT LOWER AREA PROVIDED.(� <br /> S19^ed X TIEI._ �[1�f./'-'��- ... 0.10 <br /> PLOT PLAN rn,—1.Sael.l P.O. <br /> 1. "AMEN OF RTPtEETB OR ROADS NFARERT TO On BOUNDING TILE POIOIPRTY. 1, LOCAT"OF HOUSE B{WAGE DISPOSAL SYSTEM On PROPOSED f#f <br /> ?. OUTLINE OF THE PROPERTY,OWING DIMENSIONS AND NORTH PIRECTPON. EXPANSION OF SEWAGE DISPOSAL BYBTEMS. IF <br /> 3. DIMENSIONEO OUTLBNTS AND LOCATION OF ALL EXIBTWO AND PT.OPORE.b S. LOCATION GP WELLS WITHIN nA MUB OF ONE HUNDMO FIFTY FT. <br /> $TRUCTUMO,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOtNITM POIOrF.RTY. <br /> IKO <br /> N 1.1 1999' <br /> = `.= SRS JU/% iljNCuL1;. ' <br /> PUBLICN-ALTI i SERO c k <br /> 1 bE►MWENT U$E ONLY i <br /> F <br /> ,. AFdla.11an Aee.pleA BY � �l-i__..._V\M!� 0.1. � Ar.. <br /> Mein Irwpoell.R Or Dole Ikmp I-peetlen By Doe R-- <br /> nootneelon In.Peellnn By b.le <br /> f _ <br /> AMvu n+Ft 12 Scta (s //e $ lila OM t tAA APC7'ro u ', �r <br /> [4'IF LEo F uT 1-6- *aT {L <br /> cy <br /> ACCOUNTING ONLY: AIOF FACT - CIS^ 0 <br /> PE CODE$ TEE FNTO AMOUNT REMITIM rNFC !CASH RECEIVED BY DATE Pff"T401VICE BEQUEST HUNIPM INVOICE <br /> P..h 11aePFh Cane _Fnvirn 17..111/071 <br />