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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O- BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 (209) 466.3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM BATE ISSUER ICempl{u M 7rlpRe{7{) AFFTWATION IR IAM BY MADE TO THE BAN JOAQUIN COUNTY Fan A PERMIT TO CONSTRUCT AND/OR INSTALL THE MAR DESCEISEO.S.EN M'MICA ENAION IB MATE IN COMPLIANCE WIIII BAN JDAOmN COUNTY OEVELOP�MiNT TIME.CNAPTTER 9-11161,..3 AND THE STANDARDS OF SAN JOAQUIN COUNTY IMUIC 11EMT11 BERVroEe,FNVIMNMENfAI HEALTH DIVISION. Joe AMMSOMR AAFNNI y,✓, �y /�G�1A�yi/1 Imo__clry /� r e- PARCH RIZF/A1NI oWlNns NAME,&n-ht ]e hf� ,n.a-�yy.Y'�°TRFes_ �!/�/� pOI>C O�11�/9J 7 aroNE/ CONIMCTOR�r e_,-�,� E!GL �NE� MTIIFBS PO�C I o LJG,n 1Z�11C/ys r1� PIN)NF I A�� ` 7 PVR CONTRACTOR ADDOFBS LICK MIONE I TYM OF WELLIPUMP• ❑ NEW WELL ❑ REMCEMENT WELL ❑ MoNnonwo WAIL• ❑ OTHER ❑ mmgTAILATNIN ❑ WELL BY TEM REPAIR ❑ CTOPS{ONNECT REPAIR [I VAPOR EXTRACTION WELL I J S u� 4.2!❑Room, N.P. DEPTH NMP SET__FT. FIRST WATER LEVEL a p� UVM Or MMPI ❑ wFor arnVICE WELL ❑ OEORIYRICAL WELL I ❑ RUR RDIVNa R p ❑OFBIRDCTNIN• V IN NE—H—DE–Dusf IyPE Of WELL CON{IRUCIION WECIFICAl10N{ A ❑ IMURTMAL OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO T ❑ Rlvc ITYOVAM ❑GRAVEL PACKISUE YYrr OF CARINGIRTEMMVO OU.OF WELL CARING O M1111CIMIRACMAL ❑DAIVFN DEMN OF OROIR SEAL SPECNICA710N A ❑ IPIRInATIONIAG ❑OTNER GROUT SEAL INSTALLED BY GROUT STAND NAME F C ❑ MOMTOGINO GROUt BML Molt ❑Yoo El No CONCRETE PEDESTAL 9Y DRIVER:❑Y� ❑N9 3 S APPROX.DEPTH LOCKING CHEBI En ROXIBTOVE PIPE S HLOPOSED COM{OIVCNONG A M NG METHOD: MUD ROTAHYAIR ROTARY AUGER CABLE OTHER Cr I HERESY CEn11FY THAT I HAVE EREPAMO TIIIB AMICATION AND THAT 711E WOH(WILL RE TONE D ACCORDANCE WAIT BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND MLES AND MOLKATIONS OF THE BAN"AMIN COUNTY. HOME OWNER OR LICENDFO AGENT'S SIGNATURE CERTIFIES Tim roMOMEO:'1 CERTIFY THAT D THE PEMORMANCE OF TIIF WOW fall WHICH line PHIMIT IR ISMIfD,I SHAT!Nor FMMOY MRNUNR SUBJECT 70 WORKMAN'S COMPENRANON"WOOF CALIFORNIA.- CONTRACTOR'S Ie1eNO OD RUR commcTm661GNATUOE CERIItus TM roMoW1NG: -1 CERTIFY THAT WINE MOFOOMANCE Or TIN Mae POn WHICH 71119 PERMIT It MOVED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWR OF CALIFORNIA.- "I APPVCANI MUST CAM 24 Nauru,lSo ADVANCE FOR ALL MGUIMO II/MKCNON{AT 12")Ae{ 22. COMM"E na^WNG AT LOWER AMA FolIVIDEO.Q BIer+I XC,/ AJN� ��/ I KML/4/1/`� TIN. ! OIF A A__�S�A D.t. ✓ �//�� PLOT PUN 10—le R 0.1 1. NAMES of RTMFTS OR ROADS NEAREST TO On BOUNDNn TIIF I'IOPERTY. 4. LOCATION OF HOUSE SEWAGE OImORAL BYSTEM On ITOMSED 2. OUIl1NE OF 111E PROPERTY.GIVING DIMENSIONS AND HOME DRECTroN. EXPANSION OF BEWADE DIS OM SYSTEMS. 2. DIMFNAMMO OUTLINES AND LOCATION OF AIL EXIITIMO AND PROPOSED S. LOCATION Or mun,WD111N RADIUS OF ONE NUNOnED rIFTY TT. BTRUCTUMS,INCLUDING COVERED AMA$SUCH AS PATHFe,DRIVEWAYS,AND WALK". ON THE PROPERTY OR ADJOINING PEIOMIR Y. S _ E n DEPARTMENT USE ONLY Z APPIbE1Nn AEerolwl Ry D.IE / A,M /gyp arOn NNPAEIbn Br Ie Pum019NPmIl9N By am. E 7 aom—lbn ImnmI1M1 SY D.b C.--.". ACC011IIrINO OMLYt AID/ rAC/ II coo" FEE IMO AMOUNT REMITTED TICK/ ASH RECEIVED Ey DATE POWITISCIVICE MOUERT NUMBDI INVOICE O OIS o i O 436-a� Pub.Health Sam.-Embo.173(3196)