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)7v <br /> 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 /> (209) 468-3420 (� <br /> 1110N-REFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDI <br /> (Complete In TrIpReEtel <br /> APPLICATION IS HEM BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDAR INSTALL THEM RK DESCRIBED.TI IIB APRLIC AT ION IS MADE IN COMPLIANCE WN 11 BAN <br /> JOAOUIN COUNTY DEVELOPMENT TALE,C/HHAAMFR B-111 .3 AI THE STANDARDS OF BAN JOAOUIN COUNTY MBI C 1 EALTH ERVICEB,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AOOMBRAR APSE L CITY PARCEL SIZVAMI <br /> OWNER'S NAME ADDRESS PI(`NT# <br /> CONTRACTOR ACOMBS { D UF,�03) MORE AAfi127' <br /> BUB CONTRACTOR ADDRESS UCI RIONEE <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITOR"Ml-t E ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPO"EXTRACTION WELL F - J <br /> ❑Nwv❑R.BN• NP. DEPTH PUMP SET_FT. FLASTWATERLEVR ( A! YIVICI� O <br /> HYPE OF MMPI RE0E1V*E J <br /> I^—I7�///�////��L �❑ O�VTOF-BE/R/y//[,E WELL� �Y/]I�f��1/GEOPHYSICAL WELL I ❑ ROIL BORING S <br /> N: /YXn! L /L(M.Cl , %V/1—WYL./T/ A" Y L, FP-ji <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> IJ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTORE1E11ttdFlQUiI a UOO I' D <br /> ❑ DOMESTK;mRIVATE 11 GRAVEL PACK/SRF TYPE OF CASINGISTFF K. CIA.OF WELL CAB F UBLIC LO <br /> ❑ PUBLIC/MUN1CIPAL ❑DRIVEN DEPTH OF OROM BEAL STIECIFICATION ENV R <br /> ❑ 1RROATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT BEAL PUMPED: ❑YW ❑No CONCRETE PECESTAL SY DRILLER:❑Yim, ❑Ne S <br /> ANIo011.DEPTH LOCKING CHESTER ROX/STOVE RPE <br /> 5 <br /> PROICHIM CONSTRUCTIONARFLLINO METHOD: MUD ROTARY AIR VOTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I AAUP FRfPARED THIN NRRICATION AND THAT THE MW WILL BE DONE M ACCORDANCE WITH BAN MAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES ANO <br /> MOLMTIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S 81ONATVW CERTIFIER THE FOLLOWING!"I CERTIFY THAT IN THE PEFIFORMANCE OF TILE WGR(FOR WINCH <br /> TMS PERMIT IN ISSUED.191RALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION!LAWS OF CALSORMA' CONTMCTOR'9 HINNO OR MIB{ONTMCTMG MGNATUM CERTIFIER <br /> THE FOLLOWING: "CERT CERT THAT R THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMA IS ISSUED.1 SHALL EMROY PERSONS EUNJECT TO WORXMAN'S COMFENeATUN LAWN OF <br /> CAUFORMA." TI PRPC MVS ALL ZA HOUIIS IN ADVANCE FOR ALL MOUIRM IN R1 FCT7Fj1IS AST,URNN1 ASSJMIS. COMPLLTf DRAWING AT LOWER AREA PROVIDED. <br /> mo—e% Till. y FV[t///LyaC/ Om <br /> ROT FLAN RN—le Pow.l Seel. "le <br /> 1. NAMES OF STREETS OR SCADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION Of HOUSE SEWAGE DISPOM SYSTEM OR PROIOSED <br /> I. OUTLINE Of THE POPERTY.OINNO DIMENSIONS AIA NORTH DIRECTION. EXPANSION OF SEWAGE DISPOBAL SYSTEMS. <br /> J. DIMENSIONED OVTLMES AND LOCATION OF ALL EXISTING AND FRROPOSEU S. LOCATION OF WELLS WVHIN MONS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED ASEAN SUCH AS PATIOS,DPVEWAVN,AMI WALKS. ON THE PROPERTY OR ADJOINIM PROPERTY. <br /> s <br /> Q m <br /> pIC1 <br /> FiEC ECMIVEENT r- <br /> 19 <br /> cv SAY 312D0� <br /> /� SAN JOAQUIN COUNTY cam• <br /> PLIBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH Of wSIOy <br /> o� l <br /> EP TMr use vr <br /> Apella.ibn A—.IM By ` ��-' \ i' L ( V`'`� ^ dONLYD.R, <br /> Grein Mepmlbn By Das PVmP InePdllen By Da. <br /> r/ G� <br /> p+Incllen Irwn.alen By Del <br /> CemmRwe' <br /> ACCGUHTWOONLY: AIOA FACT <br /> PE CODES FEE INFO AMOUNT R!rITTED CHECK ASH RECEIVED SY DATE PEEAITIem"CE RFOIhST NUMBER INVOICE <br /> Health Sew -EDVIF0 173(1/97) <br />