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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES " v <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmpletB In TrbRe@tBl <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TI118 APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TREE,CHAPTER9-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUP PUBI/G HEALTH//SERVICEB,ENVIRONMENTAL HEALTH DMBION. <br /> JOB ADOREGNMR AMI J 4l'I.r•,/` / CITY y'y PARCEL SIZE/APNI /}/ /�z <br /> OWNER'S NAME I�1 G Ili{H S r I�/C S `C CJ AMPE8B ( �J Q �/ MORE I ll Li5ZV� <br /> CONTRACTOR //�Q /{1S, L Y,L IIIKG' ADDRESS II� /'FPr^L uct� -VV2Z PHONE V2Z 1Vz <br /> am CONTRACTOR ADDRESS UCI PHONEI <br /> TYPE OF WELLMUMP: ❑ NFW WELL ❑ Rtr ACEMENT WELL ❑ MONTFORINO N/ELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR098 ONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑N—❑R w' H.P. OEM"PUMP SET FT. FIRST WATER LEVEL O <br /> R YPE OF PVMPI <br /> ❑"" OOTdF-SERVICE WELL 1 00 GEOPHYSICAL WELL I Cl SOIL BONNO B <br /> INTENDED USE TYPE OFWELL coN{TRVCIIOM SPFCIFlCATIONS A <br /> 0INW6TRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMEBTICA VATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL DIA,OF WELL CASINOfLzp <br /> ❑ PUm1CIMUNICIPAL ❑DRIVEN DEPTH OF GROM SEAL SPECIFICATION R <br /> ❑ IRRIGATIONIAO ❑OTHER OROVT BEAL INSTALLED BY GROUT BRAID NAME E <br /> ❑ MOMTomM (/, OROUT BEAL PIMPED: 1:1 Y. [IN. CONCRETE PED6TAL BY DRILLER:11 Y— N. S <br /> APPROK,DEPTH )/ EJ LOCKING CHESTER BOXIBTOVE RP 5 <br /> PROPOSED CONST?lMTION/DNIUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I IIAVF PREPARED THIS APPLIOATION AND THAT THE MW WILL BE DINE W ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REDIIATIONS OF THE BAN JOAOUW COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOV.INO:'I CERTKY THAT W THE PERFORMANCE OF THE WORK FOR WHICN <br /> TMS PERMIT IB ISRUEO,1 IRIALL NOT EMPLOY PERSONS SUBJECT TO WORIIMANY COMPENSATION LJ.W'S OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING MONATURE CERTINES <br /> TIRE FOLLOWINGS -I CERTIFY THAT W TNF PERFORMANCE OF THE WOR(FOR WHICH THIS FERMI IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPfNSARON LAWS OF <br /> CAUFORRI I l APPLICA�N/T�MUST G�AyLL 3DA/I/�KI')(U/1/IN ADVANCE FOR ALL REOUMED IMSPICCIDONS AT UMN AH-f1}S, COMPLETE DMWINO AT LOWER AREA PROVIDED. <br /> al'r X L ✓ VL a V4�'W H/ `J / I I l-C D.J. <br /> K. <br /> r PAT RAN Rblo.1.S..I.1 Ae.b 'to <br /> I. NAME@ OF STREETS OR ROAD8 NEAREST TO OR BOUNDING THE POPERTY. 4. LOCATION OF HOUSE SEWAGE DIBPOBAL @VSTEM OR PROIOBED <br /> 2, OUTLINE OF THE PROPERTY,OIVND DIMENSIONS AND NORTH DIECTION. EXPANSION OF SEWAGE DBPOBAL SYSTfMB. <br /> 1, DIMENBIONTO OVrLWFB AND LOCAYION OF ALL EXISTRM ANO PROPOSED & LOCATION OF WfLLB wrFmN MOWS OF ONE HUNDRED rtF FT. <br /> STRUCTLNIES,INCLUDNO COVERED AREAS SUCH M PATIOS,DPVEWAYS,AM WALKS. ON THE PROPERTY OR ADJ)INRM PROPERTY. <br /> i+ <br /> JUL <br /> PUBUC HEALTHSERVICES <br /> ENVIRONMENTAL HEALTH DIVI <br /> S(J. <br /> TMFNT USE ONLY <br /> L <br /> G <br /> Gr WI lmpeelbn Br GN. PUTF Impeellen BY O.I. <br /> OPlnetlen Iwn.abn Br <br /> y eo C➢NC Pup PID �R2 aeQ c -< <br /> ACCOUNTING ONLY: AIDS FACT <br /> PE CODES FEE INFO AMOUNT REMITTED C HICKS ASH RECEIVED BY DATE PEPARITPFA CE REOUEST NUMBER INVOICE <br /> 3 (PS- {` <br /> Pub 4eeltR Serv.-Ewro. 173 (1/97) <br />