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APPLICATION FOR WELL/PUMP PEF T <br /> S . JOAQUIN COUNTY PUBLIC HEALTH St-WICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 a ST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON- EFUNDADLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> //�f <i.O i.(-E"/� �p<'i-'R.•Ir..." > /1O ICempMR In TrIpDER111 <br /> APPLICATION M ASIS BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INRTALL THE WOW DESCRIRED.TITIN APPLICATION 10 MADE IN COMPLIANCE W1111 BAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1119.3`1 AND 71M STANDARDS OF RAN JOAOUIN COUNTYY/P)BLIF/IIMAyR l SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JON ADDRESRIOR 1/A,YPINOF/),"jC el(p- .\.>'1/C/. (,!/,�f/l/1T �h/1'!J,/ �;! CITY /(x_ Il'l' \ PARCEL R12E1A1'NI /D :ocY�j <br /> OWNER'S NAME �/ )1 A t- / ./ CfC'11 j Cr�.��1 TOAD✓k/t I('YP�^I A"tuMSR PHONE I <br /> CONCRACTOR� /��� �� f lrr /�'L� ADDRESS A ✓ HCS (NONE/yZ I,,7 <br /> ( / ( _ADDRESS E 1 , 4�UCS RHONE F,�Lp�j�.17I i <br /> TYPE OF WE�MP• NEW WELL ❑ REPACEMENT WEII ❑ MONROnINO WELL I ❑ OTHER _ <br /> bI /, Cl MSMLUTION ❑ WELL SYSTEM REPAIR ❑ CROSRCONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> I J <br /> �4 yv N�nv❑neP.lr H.P. DEPTH PIMP s"46-'r. WATER LEVEL /Y//. O` <br /> D VPE OF P1MP1 <br /> ❑ OUT-OF-SERVICE WELL ❑'GEOPHYSICAL WELL/ ❑ ROLL BORHIO <br /> ❑DERInUCl10N <br /> T> <br /> INTENDED URTYPE OF WELL CONSTR TION/ ECIFICATIO �/�/�/�/�_�qqqq/J AINOU ( / <br /> ❑ DOME9TWI ❑OPEN L TTOM DIA.OF WELL EXCAVATION DU.OF CONDUCTOR CASING p <br /> A❑y nOMERLMSYVVATE GRAVEL PACK/SIZE TVR OF CARINURTEU.'PVOV VIA.OF WELL CASINO D <br /> {L PURLW MUNICIPAL DRIVEN DEPTH OF GROUT REAL /H�t / SRCIFK;ATION • S /_ U n -� <br /> /❑ InAIGAIIONIAG ❑OTHER GROUT REAL INSTALLED <br /> (E�BBY (,I�. GROUT BRAND NAME .4tyllel-et—1 [IN. E <br /> N <br /> ❑ MONITONO 'JL `_ / GROUT REAL NMRY.yp Y ❑N4 CONCRETEPEDESTALBYDRLLEn,0Yw Ne 3 -> <br /> APPROX.Of"" r� 7.J LOCKING CHESTER NO%/STOVE PR i «T <br /> �\ <br /> PROPOSED CONer"m IIONIdOWNU METHOD: MUD ROTARY_/AIR RDTAW AUGER CABLE OTHER S, <br /> I IIFRFRW CERTIFY THAT I HAVE FTEPAOED THIS AITRIOATION AND THAT THE WEIRK WILL BE DONE IN ACCORDANCE"IN SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,ANDMASS AND�'��( <br /> "FIVNIATIDNR OF THE SAN JOAGUAR COUNTY. HOME OWNED On LICENSED AGENT'S 91ONATURE CERTIFIES TINE FOLLOWING:'I CERTIFY THAT IN THE RWOnMANCE OF THE WOB FOR WHICH <br /> THIS PERMIT IS ISSUED,I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'R MINING an SUS-CONTRACTING SIGNATURE CENTRIES <br /> TIM FOLLOWING: 'I CERTIFY THAT W THE PERFORMANCE OF TINE WOR(FOR WHICH THIS RRMT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAIDORMA.- TINE NT MUST CW02'11 <br /> LL 4 MGM$IN ADVANCE FOR ALL SECURED INIMPIONS AT 12001480-3422. COMPLETE DRAWING AT LOWER AREA RIOVIO <br /> .1 )> n eC; () - <br /> SI.eN X �[7•'ILeQ.CM TITh prl 1 <br /> POT RAM Nr.w Ts SaN.I ReN. <br /> 1. NAWR OF RIRFTS ON MADS NFAIM..RT TO On ROUNDING TINE PROPERTY. 4. LOCATION Or I IOVRE SEWAGE RSPOSAL SYNIEM OR PIOPOSED <br /> Z. OUTI INE GF THE PROPERTY.GIVING DIMENSONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2. DIMENIrONF.G OUTLMFR ANO LOCATION OF ALL EXISTING ANO RIUPOSEO S. LOCATION OF WFLLR WTIIN RADIUR OF ONE HUNDRED PrTV FT. <br /> STRICTURES,YXIMMMO COVERED AREAS SUCH AR PATIOS,DRVEWAYS,ANO WAUU. ON THE PIIOPEITY On ADJOINING PRORiHY. <br /> Ilk <br /> CEPARTMENT USE ONLY <br /> APPn R AeeeeleM Nr <br /> —DSI./) �I(' `{ Pune In.PenGen BY <br /> D.I. <br /> Owbrw,tlnn IRISH.',Rr wb <br /> /NrGS —E ,FL Ln 'O.'O C. clC) 1--K '/ f'C/^ <br /> ACCOMrUO ONLY: AIDS FACT <br /> PE CODES FEE Into AMOUNT REMITTED C{ CKIMA51 RECRVED ST DATE IDSMI VSFRVICE REQUEST NUMBER INVOICE <br /> I 1 <br /> Pub.Health Serv.-EnWro.173(1/97) <br />