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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JUAOUIM ST., STOCKTON.CA 58201388 <br /> (2091468-3420 <br /> NON REFUNDABLE PERMIT EXPIRES 1 VERB FROM DATE ISSUED <br /> B+IepNa N Tripiiea W <br /> Application is here by made to the San Joaquin County for a perm!t to construct and/or inaLlL the mark described. This appLicatim is <br /> made in compliance with San Joaquin Gdnty Dewtupaent Title,_CAapter fl153/.y he 6tada.,rd..s of San Joaquin Can[Y P.ltic Wealth <br /> Services, EovironTntall Weealt`h�Dtviai min„ 6C�d.�r�lOVt 7�.rY 4a,2 r d— <br /> Job Address/or APMN L/�:5 /YLt,1��—Z7:3,�J Q/r-�J���-City L�N/(/L�� �iPerc*l S[ae/APRR_ <br /> Owner's Nawar 7A"tF�/T/4 //[LL!-l��tla�r�Addrrees. a ZE �J'�/i5/HC Mare IR <br /> Contractor_y I/"/� / S'�6�sJ✓./.c��AttlreGS �y/rte/J) .�IJ(GC[I Lick Phare E <br /> Shb Contractor /S�J�UN//t�hS AW' Address L� /"P_(Q= dfc% LicR a�a0 r3 Ph.t.SLI.�-��N <br /> TYPE Of YELL/PUP: 1Y NEW WELL 13 REPLACEMENT YELL 13 MONITORING WILL R (1 OTHER <br /> 11 DESTRUCTION 11 OUT-Of-SERVICE WELL 1) GEOPHYSICAL WELL Y [7 Wil WRING <br /> 92 11 INSTALLATION ❑ WELL SYSTEM REPAIR ❑ OROSS-CWNECT REPAIR 11 VAPOR EXTRACTION WELL R_ J <br /> _ iiJ ,7TNev 11 Repair N.P. DEPTH PUP SET ifid VE <br /> IT. FIRST OUTER LEL 1.57/—f p <br /> (TYPE OF PU 13 <br /> IN1E•OEO USE TOE OF MELL WRRTRUCEION SPECIFICATIONS l/ �— <br /> ❑ INDUSTRIAL AAAU��_OPEN GOTTEN DIA. OF WELL EXCAVATION /L DIA. OF COIMICTOR "SING <br /> . ME <br /> 'DSTIC/PRIVATE I<-IGRAVEL PACK/SRW__ TYPE Of CASING/STEEL/PVc EIA- OF WELL CASING A�.y <br /> LI PUMI <br /> BLIC/ NICIPAL/[3y DRIVEN DEPTH Of GNWT SEAL SPECIFICATION <br /> P <br /> IT IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY /HUR//YJL,f S GMT BRAND MMM <br /> ❑ NGNIIORING /. GROUT SEAL INANPEO n [I We CONCRETE PEDESTAL BY DRILLER: 1] Yes [I We <br /> APPROX.DEPTH J LOCKING CHESTER WX/STOVE PIPE <br /> PROPOSED CONSTRUCTIOMIORILLINU METHOD: XW BOTANY AIR ROTARY_NIGER_GDLE_OTHER_ <br /> I hereby corti fY Met 1 have Prepared III,a application and Chet Me York YI[L he dans In aLCOrdMKC Yiih SMI JoaW(n Canty Ordfnarcea, <br /> state Leve, and Rules and Re stAtiont of the Sar,Jwgl!n Canty. Mas Omer or licarwad agent's signature certifies Ma fel Lowilg: R <br /> certify that in the perfomMce of the York for which this permit is issued, 1 Shall not splay par&"slbJst to YDNRIUM'S O ENSATION <br /> Laws of CeUfarnie." Contractor's hiring or soma-contractin, signature certifies the following: r 1 cartify thet in the performance <br /> of the mark for Mich this permit is 11SUed, I aha L1 onoLpy persona adolact To YDRANANIS CEWENSATIW Laws of California.- TMEAPPLYCANT <br /> MUST CALL 14 ADC �gT1/�C/�//,. POUUIIRIED HIISSPPEECCTMNB AT(kill SNB.i423. Carplete drwinB at Lower area prooy,iiidd�ed. 1, <br /> Signed A Z1 /// ;%�'v'.' � Title 1 s'« <br /> PLOT PLAN (Draw to Scde) Scala^ to <br /> 1. Mama of streets or reads neeraat to or beading the property. _ 4. Location Of house sawage disposal •ynon or <br /> Z. Outline of the property, giving diPermiona Md North d[rectfan. proposad"Fenalon of steels disposaL systas. <br /> 3. Disensionad outlines And location of It existing Md proposed 5. Location of weLls within radius of 150 it. on <br /> atnictures, ircNWing coverad arses such es patios, driveways, the property or adjoining Property. <br /> and walks. <br /> s <br /> 0 <br /> N <br /> ,V V <br /> n <br /> !UO C AL HS HU. E� <br /> DEPARTMENT USE ONLY 6756 <br /> Applicatlon Accepted By [[ Date Arp �. an <br /> Grout lospectian BY nete� Up Inspection a Data_& <br /> Destruction Inspection By.Date Coepents: <br /> ACCOUNTING ONLY: AID# FAC* <br /> PE ODES EEE MFG AY T REYITTEO CNE ACASN RECEIVED BY DATE PERYITISERVICE REQUEST NUYREN INVOICE <br /> l' O - AVl� <br /> S p Iq <br /> ` S?L000 X181 1 <br />