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k <br /> APPLICATIORI FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> F304 EAST DIESER AVENUE,STOCKTON,CA 95202 <br /> (209)465-3420 <br /> WOR-REFUNDABLE PERMIT ERPFRES 4 YEAR FROM DATE ISSUED <br /> ILBBIpbtM IB TTIpDcEIBI <br /> F, <br /> APPLICATION..REMBY MADE TO THE SAN JOAOVIN COUNTY I.A.A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORT DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WTII SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 5-1115,9 AND TZ119 OF BAN JOAGWN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH LIMCIDN. <br /> JOB AOOREOMR.APHIl��'fl 1EyY']7~ A`LSrr CITY J,C '� _ _ PAMEL BRE7AHNF <br /> FOWNER'S NAME 33 // /LQAppp.EBB / �jJ�Y,j /� PHONE f n <br /> CONTRACTOR C TET ` -�Ya/ ADDRESS�U ('�,{7(/J(f/f/rrj- 11CA7534�2 PHO NF/ <br /> BUB CONTRACTOR ADDIIFSB UCR PHONE F <br /> TYFEOP WELVPUMP: ❑NEW WELL r❑RPPLACEMENr WELL Q MOMTOBINO WELL I 13OTHETI <br /> ❑INSTALLATION CI WELL SYSTEM REPAIR ❑CROB6CONNE-C7T REPAIR 13 VAPOR EXTRACTION/WELL F J <br /> ❑"—Q F.W, H.P. !'s DIFTH PUMP BFT/Q PT. FIR03T WATER LEVEL 7 7 O <br /> ITYPE OF PUMPI I0""I7 � <br />, � ❑OIIT�OFBERYK:E WEII ❑GEOPHYSICAL WELL I ❑ SOIL BORING S <br /> ❑DESrRUCTHoN: ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑INDUSTRIAL ©OPENBOTTOM DIA.OF WELL ERCAVATON DIA.OF CONDUCTOR CASINO O <br /> ,KDOMEBTICIPPVATE ❑GRAVEL PACKISIZE TYPE OF CABIMHBTETLUPVC DIA.OF WELL CASINO O <br /> Fj, <br /> 11 PIBLICIMUMICIPAL ❑DPIWN DEPTH OF GROUT DEAL SPECIFICATION R <br /> ❑IRRKLAT70NIAG ❑OTHER DROVT SEAL INSTALLED BY GROUT BRAND NAME F <br /> ❑MOWFUNNO , GROUT EEµPUMPED:(3rYa A.J-TI Ne CONCRETE PEDESTAL BY DRILLER:❑Y.. (IN. S <br /> APPRO R.oP9IT1 :29 ..L � LOCKING CHESTER ROXMTOVE RK 5 <br /> PROPOSED CORSTRUCTIONIORILUNO METHOD;MUD VOTARY MR ROTARY AUGER CABLE OTHER <br /> I. 1 HEREBY CERTIFY THAT I IIAVE PREPAREO 1H1E APPLICATION AND THAT THE VMRL WILL RE CONE RI ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND AULEG AND <br /> REGULATIDUR OF THE SAN JOAQUIN COVNTY.HOME OWNER OR LICENOCV AGENF'S SIGNATURE CERTIFIES THE FOLLOWING!'I CERTIFY THAT IN THE PERTORM E OF TIR wow FOR WHICH <br /> THIS PERMIT IS IBSUEO,1 SHALL NOT EMPLOY PERSONS 81JOACT TO WORKMAN'S COMPMIATION LAWS OF CALIFORNIA.'CONTRACTOR'S IGRNO OR DUBCONT TING SIGNATURE CERTIFIES <br /> THE FOLLOW"G '1 CERT THAT M nlE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB MOVED,I SHALL EMPLOY PERSONS SUBJECT TO WYORKMA 'S COMPENIIAT1ON LAWS OF <br /> F <br /> CAUFORNIA.' THE MU//IT CALL 24 HOURS IN ADVANCETOW ALU.REH4mm UdIPECTIONB AT 12"14",24.,COMPETE DRAW WG AT LOWER AREA HOED.ROT PLAN Ml—la Sahel 9-1. '10 <br /> 1,NAMED OF STRETTD OR ROADS NEAREST TO OR BOUMNO THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE 046POBAL SYSTEM OR PROPOSED <br /> E.OUTLINE OF THE PROPERTY,OrYM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> 7,DIMENSIONED OVTLUNF,S AND LOCATION OF ALE EXISTING AND PPIOPOSFO B.LOCATION OF WELLS WITHIN RADIUS OF ONE HUIOREO HFTY FT. <br /> STRUCTURES,EICLUDINO COVERED AREAS SUCH AS PATIOS DRIVEWAYS ARO WAlKB. ON THE PROPERTY OR ADJOINMO R°ROIERTY ' <br /> Inl , <br /> W <br />` T <br /> J <br /> Fi, <br /> t <br /> J <br /> 1, <br />