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APPLICATION FOR WELL/PUMP PERMIT �go 4 SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I 304 EAST WEBER AVENUE, STOCKTON, CA 95202 ERMIJ 468.3420 T i re A o ^y NOW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � " 1{! (complete M Tr(pReeT/I APPLICATION IS HERE BY MADE TO THE BAN JUAOUIN COUNfY FOR A PERMIT TO CONSTRUCT AMIOR INSTALL THE MAK MOCRISM.TIRE APPLICATION IS MADE m COMPLIANCE WRIT BAN JUAOUIN COUNTY DEVELOPMENT TRIS,CHApTR18-1/11 B./7 AND THE AMS OF SAN JOAW COUNTY PUBLIC HEALTH SERVIOES,ENVIRONMENTAL HEALTH DMOIOH, JOB AOOREBSMA SPN,1/Z�+yy�_J!/ [j'QL �a( CIn��/�J ,/� /' /1 PARCEL BIZE/APN/ OWNER'S NAME I✓1['IIA/r N /Dyp'E O�/ AO011EB61GyA .oC7�•1O//T �C�II� ��- R10Nt1368 CONTRACTOR �/f= L r� 1 (�.1M,0 ADDRESS 1 O BO1C am CONTRACTOR ADDIIMB LIC) PHONE I TYPE OF WELINUMP ❑ NEVI WELL ❑ REPUCEMFNT WELL ❑ MOMTONM WEIR I ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR 13M CSB ONNEC�T�REPAIR ❑ VAPOR EXTRACTION WELL I S b 11N«.®ROW N.P. DEPTH PIMP SET %Y FT. FIRST WATER LEM SE O STYPE Or PIMPI ❑OUT4)F-ftBR C -e ❑ OMPNYBICAL WELL POR BONNO I ❑ _ B ❑tNeaRDcxror� J!/�[t�C/�LC�HcA� .t-�Y� /L-Q�.J-GE-t-c/g�✓L�P�f-2-LC.c�� L/-P�[/ � INTENDED Uif TYPE OF WELL CONSTRUCTION SPECIFICATIONS tI A ❑ IMmrmAI 11 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O IU-DOMEBTICIE'NVATE E]GRAM PACK/We TYPE OF CASINGMTEEL/PVC DIA.OFWELLCAVM O ❑ M"M MUMCIPAL ❑DNVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ N N IATIONIAG ❑OTHER GROUT SEAL INSTALLED BY OMUT BRAND NAME E ❑ MOMTONNO OMUT BEAL PUMPEO: ❑Yoo 0 N CONCRETEPEDESTALBYDNLLER:❑Y— ❑He 5 APPIl DEPTH ��i/ LOCRmO CHESTER BOXMOVE PR S PROPOSED CONSTRUCTIONNNLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY'THAT I IIAVE PREPARED THIS APMATION AM THAT THE MAK Y/ILL BE DONE N ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RITES AM REOLAATIONS OF THE SAN JUAOUN COUNTY. HOME OWNER OR LICENIED AGENT'S SIGNATURE CERTNIES THE FOLLOWINO:'I CERTI THAT N THE PEROIMAHOE OF THE WORK MR WHICH TWO PERMIT IS ISSUED,I SHALL HOT EMPLOY PERSONS"ACT TO WORKMAN'S COMPDm AMN LAWS OF CALIFORNIA.' CONTMCTOR'B HIIBHO OR OLRCONTRACTM MONATURE CERTIFIES THE FOLLOWNO: -I CERTIFY THAT N THE PERFORMANCE OF THE WORK MR WHICH TWO PERMIT IB MOVED,I WALL EMPLOY PERSONS SUSIECT TO WORBMANYS COMPENSATION LAWB OF CAUMMI A/.',/STI/NA/pfLICA�yNi^OOT CALL SI NO IIBIIM AOVANC/555FMAAM.11EONINO/mBl6TJq�N�S AT fMe1 AY-fA26. COMPETE DMWINO AT LOWER AMApIP'O DEO. /7 61p,s.X/,ifi7[/41Ad Z Tae�•S.f_i D.IL:J z ROT MN IM.1.BewN Bele. 'Is 1, NAMES Of STREETS OR MADS NEAREST TO OR BOLNpRM THE PROPERTY. S, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On POMSM i. OUTLON OF THE PROPERTY.UNIM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL OYtTEMO. T. DIMENSIONED OU11JNFS AM LOCATION Of ALL EXISTING AND P10MSfD S. LOCATION OF WELLS IARMN RADIUS OF ONE HUNDRED FIFTY FT STRICTURES,NCLVOIM COVERED AREAS SUCH AB PATMO,DNVEWAYS,AM WALKe. ON THE PROPI RTY OR ADJOINOIU PROPERTY. V. 0 PAYMtr N a; AUG 9.71999 \\ - PUWJC HEALrR SERVICES V eIVVtR0NhTENi"gj.HEALTH DIVISION s J 7 CI'^ � .. � Aeon..I n Ae.. WEN BT " T DeB -Z A... a'."w Ilan OI DH. P me konood.II By YV 6toa O.L. d 4 D�n4uallen I,weFmlen flv O.S. Cemme,e.' ACCOUNTING ONLY: AID/ FACI PE CODES FEE Iwo AMOUNT RESEqTEb CHECK H RECEIVED BY DATE PERMITINFR"CE REQUEST NURSERS INVOICE U5 9/-L-7 3 Pub Health SeN,-Enviro.173(1/97)