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T CSO 5.7�•� I APPLICATION FOR WELLJPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 MORI-REFDIIDA9LE FEWT EXPIRES I YEAR FROM DATE ISSUED IC.mMI.0 IR Ttlp k.t.1 APPLICATION IS HERE 9Y MAGE TO 711E SAN JOAOIIR7 COUNTY FORA rERMIT TOOONRTRUCT ANDI n INSTALL THE won't DE SCRINEO,TIME APPLICATION IS MADE IN COMFUANCE WTTN BAN JOAQUIN COUNTY OEVEI.OPMfE'NNIT TITLE.)CHAPTER 0 1115.3 AMC)THE STANDARDS Of SAN JOAOU1N COUNTY PUBLIC HIEALI"SEEAVICEN,VIR INONMENTAL T/M HEALTH SON, JOS A00RESRI7R APNf .T �i �/C /��/��•�✓ C— T, T"/y zo, !&-/l PARCR h2E/M'NI k/ IC/ OWNER'S NAME_ C-/�(�C`l�-` /72 �f C74 u'�/l /"f2 AOUREBS .7L RN)NEI /�/CTJ[. CONTRACTOR_( rL !/y/l) pu A?,�• ��Lil C y� ADDRESS C� G-' /,�/moi G1,/�LICI / rN041 IF 2L!"y/� PLUS Co NTMCTOR_ „----II ADOP[.e y UC'--14,40.S LIR EYPE OF WEUMP: ❑N.`W WELL 0 AFMACEMENT WELL ❑MONITOSINO Mi L I ❑OTHER ❑INSTALLATION ❑WELL RVR TEM FIEPAM ❑GROS.CONNECT REPAIR ❑ VAPOR EXTRACTON WELL IF_ ❑H•w Ra411o.I. "'p. TJEPTH PLJAAP SE7• �TI Finer WATER LEKt_ !/n i ' d6 HYPE Of PUMP E-� ❑OUT-orRERVICE WELL ❑OEOPIYSICAL WELL. ❑ SOIL eORINU r 1 lJ OESTRIICTW N: INTE/l EO USE TYPE OF WELL CONSTRUCTION IFECFICAIION. A I ❑INOUSTWAL ❑OPEN SOTTO'. GIA.OF WELL EXCAVATION DIA.OF CONWCTORCASINO D ' ❑DOMFSTIC, VATS ❑GRAVEL PACSIS!7F "PC OF CAS1 MIFFR JPVC DIA.OF WELL CASINO O g ❑r'LIBLICRAIP—AL ❑bRIVEN OCPTH OF GROUT REAL SMCIFICAM” S (Y 0 IRIIOATIONIAn ❑OTHER GOUT REAL INST—Fo RY GiCVT BRAND NAME E 4\ ❑MOMTONNO nROUT SEAL PUMPED:❑Vr ❑N. CONCRETE PEDESTAL MY MULLEN❑Y— ❑II• _ APFROX.DEPTH LOOSING CHESIFR BOX—OW HPE__ S PROPOSED COM.TRUCTOWOFSWFFO AMMOe:MIA ROTARY AIR AOTARY AUGER _CARLF OTHER I HE9ESY CFRTFY THAT I HAVE PREPARED TMS AIEEJCATION AND THAT 111E WOF*(HALL RE DONE IN ACCORDANCE MATH SAN JOAQUIN COUNTY nRO)NANCES.STATE LAWS.ANO RUT ESHO A ' TFMR ATIONR OF THE SAN JOAOUW COUNTY,HOME OWNER OR MENSFD AOF1R'S SIONATURE CERTIFIES THE FOLLOVANG!'1 CERTIFY THAT IN THE FEWORMANCE Or TIIE WOPR FOR MIMIC" THNL NOT EMPLOY PERROFA SUBJECT To WaRRMAN'S COMHNSATION LAWS Of CA(IFORW.A.'CONTRACTOR'S HSSNG OR BUS-CONTIUAC TIM SFONArURF CERTIFIES TIIS PERMIT IR Memo.1 SAI If FOLLOWING: 't CEnTIFY THAT IN THE PERFOWANCE OF THE WORK FOR WHICH TNIR PERMTT is I..UEb,1 SMALL EMPLOY PERSONS SUBJECT TO WORIOAAN'S CGMPVI.ATION LAWS Of CILLROFOAA." U411 A41JO ANT MUST CALLSS HOURS IN ADVAMCS FOR ALL R.OLRREO IIISPSCTIONS AT ISOSI A"JHSS,COMPETE DFLAWINO AT LOW"AREA PFIOM10 0. SI—I X_I / �.,ja'S :1 •'.: - �rIMA fi' [/" l�� Ga. •J � '�y MOT PLAIT(V—1.Re.1•I S—I• •L• 1.NAMFR Or STIEFTS OR ROADS NFAMW TO OR SOLEI VNa THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR IROrOSEO i. OUILWF OF THE FEIORRTY,OIVWO bMENSNINS AND NORTH DIRECTION. EXPANSION OF SFWAGF DISPOSAL SYSTEMS. J. D.—.mNED OUTUFFS AND LOCATRDN OF ALC EXRET—I ANO F•I POFD S.tOCATION OF YVLLL.WtTHN RNIM4 OF ONF HUMORED NFTV R. STMWIU ES,INCLUDWO COVERED AREAS SUCH AR PATIOS,DMVFWAYS,AND W.ALX8. ON THE FTOPfRTY OR ADJOINING PFCFEFTrY. I w. /, k "RCA: /A� c�k 11 7 � � � I��;;��:{��•I . ,nn ll�� MAY: 2199$ ✓iJ;'i I ft sAri:�.}reulrsc,i w�l� VUF31lC:1='LUN SERVICi.o I G14V1ri0NM1--N":A:_HEALTH r.)M&ON DE"TMdT USE ONLY A,plr•Ibn Ar•—d eF \"r!i ti~t'.��•.� T D.a ' Gia�l MI•,c11•r,S, CC"".. "�'—� br. �—'-=• � �_T L—,1 S" N.•P RTIRIAti.n W I��+ _�DII• (rte"�'/<--. � 1 " ACe.UNT/NO ONLYe ACI FACE If COOF. FEE INFO AMOIIIIT RENS TTFO C1fEG MN RECEWFO MY DATE FmMITFSER"CE REOUEST NLIASm INVOICE Pub.Health 5— -EnVIrO.173(1197)