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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 /> ( ) 468-3420 <br /> NOR-REFUNDABLE PERMIT EX68.34 1YEAR FROM BATE ISSUER ORIGINAL <br /> (CempMtt M TdpRuts) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANT OR INSTALL THE WOR(OESCHIFIEM THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPMENTTITLE,T ITITLLEE,CHAA�PTER 9 11115...3 AND THE STANDARDS OF SAN JOAWIN COUNTY TIC 11EALTr1 SERVICES,ENVIRONMENTAL HEALTH <br /> HE RASION. <br /> JOB A00RESSMR ARI. //� / /J 1 1 /Y.71 ko -A hlh n 4. CITY /� U//E (1 / / (/ <br /> OWNER'9 NAME / A{1 N t(/ L.. Qy a 1\c]✓T I I ADORES/ �•f• '0 1 e ox IMI( �t PHONE F yV�/ , 3/� 1 <br /> CONTMCTORAki1k(—fVCo �{1y Oh C LIQ ADORES B 1165 N/• WIIs✓H Ly4y UCI�1�FNONE( 7:1A <br /> SVS CONTRACTORSJI(41MADOTIE86 11CI RIONE I <br /> TYPE Of WEUPUMP: ❑ NEW WELL ❑ RMCEMEW WELL IP5�.ONH ORNO WELL# V ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL BYBTEM REPAIR ❑ CROBSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> ❑Nev❑Rr.b H.P. DEPTH PUMP SEF—FT. FIRST WATER LEVEL 0 <br /> ITYPE OF MINIM <br /> ❑ OUT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL A ❑ BOIL BONITO 9 <br /> ❑DEBTRUCT10Ii <br /> SPECIFI <br /> INTENDED USE TYPE OF WELL y DIA OF WELL E CAVATICATION/ PW 2- 1.3µL h AO <br /> 11 INDUSTRIAL ❑OPEN BOTTOM $� DIA OF WELL EXCAVATION r - RRL DIA.OF CONDUCTOR CASING I•//T _a <br /> ❑ DOMFSTICTWVATE 13'ORAVEL VACIK181ZE SRN TYPE OF CASINORTEEL�N' DIA.OF WELL CASINO , I/' (� <br /> ❑ IVBUCAAUHICmAI ❑ORVEN OEPTN OF GROW 6EAL )UF,C<t ( rU S , SPECIFICATION S�- l yU/r I LTV N-A— <br /> ❑ INtlOATIONIAO ❑OTHER GROW SEAL INSTALLED BY T/C MII Q GROUT BRAND NAME � I <br /> �y �J �✓ <br /> IY MONITORING '''/Y I OIOW REAL RIMRO:IpLYr (IN. { II,, CONCRETE PEDESTAL BY DRLLEFM1YJyr N. <br /> 5 <br /> /APPROX.DEPTH � ` s LOCXINO CHEATER BO%ISTOVE RPE lVd kVA <br /> PLIOPoSm COM/TRIFCTION/ORLIIMQ METHOO: MUD ROTARY AIR ROTARY AMER x_CABLE OTHER \ <br /> �1 <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS AR•UCATION AND THAT THE WOR(WILL BE DONE N ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> ROULATIONS OF THE BAN JOAOUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTNES THE POLLNIFY <br /> OWO!'I CERTTHAT N THE PERFORMANCE Of TIRE WORK FOR WHWH <br /> THIS PERMIT IB ISSUED,I MIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF CALIFORNIA.• CONTRACTOR'S MINING OR BUBCONTRACTNG SIGNATURE CERTIFIES <br /> THE FOLLOWINKI: -I CERTIFY THAT N TE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WOR MAN't COMPENSATION LAWS OF <br /> CALIFORNIA/'q/,yF1/1�1E APPICANT MV4T CALL <br /> 2A HOURS IIRR�ADV�ANCE FOR ALL REQUIRED mC/RCTIO1L7l�AT 12981/.TM-SJIS. COMPETE W1N0 AT LOWER APPA PROVIDED. p( <br /> 94-1 X Tl9. J a ! I ✓ o/f 0 y s D.I. 3 —�— 4 <br /> PLOT RUR 10,—IB a A.l lk.l. •to <br /> 1. NAME@ OF STREETS OR ROAO9 NEAREST TO OR BOUNDING THE PROPERTY. /. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS ANO NORTH DIRECTION. EXPANSION Of SEWAGE DISPOSAL @Y9TEM6. <br /> J. d NBONEO OWIINFt AND LOCATION OF ALL E%ISTINO ANO PROPOSE. S. LOCATION Of WTUS WNTSN RADN@ Of ONE HUNDRED FIFTY P. <br /> @TRUCCTURB,WCLUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKe. ON THE PROPERTY OR ADJOINNO PROPERTY. �3\ <br /> TEIEEE�, - ■ �/jam• �/�/�//�� '�O�'E�11� '. <br /> I� <br /> DEPARTMENT USE ONLY <br /> AppllRlbn AavaPlad 0Y <br /> 0'..Mnealbn @Y O.0 PvnP IrnP«Gen BY OR. <br /> Ge.u,c9.n 1rnP«Oen er - D.le <br /> Cemmr.. <br /> ACCOUNTING ONLY: AID/ FAC# <br /> PE CODES FEE IWO AMOUNT REMITTED CNECXIMASH RECEIVED @Y DATE PE8IBTISERVICE REQUEST NUMBER INVOICE <br /> 350 K" Si. 1 3- 1 <br />