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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - e <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 1 S <br /> nn A (209) 468-3420 <br /> Pev t 9,0—-s-f NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O <br /> ICemplet/M T►Iprklal �jo z t?l <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIRED.TIIIS AT'T'LICATION 19 MADEIA E WTII BANJOAOUIN COUNTY DEVELOPMENT TRLE,CHAPTER 8-1 11 B.3 AND THE STANOARDS OF SAN JOAtcOUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH O . <br /> JOB ADDRRESS/OR APNI ( v PARCEL 91ZFJAPNI <br /> OWNER'S NAME ADDRESS MOORE I L CONTRACTOR LL�t �( J PHONE I � <br /> SUB CONTRACTOR ADORE88 LICI PHONE/ <br /> TYPE OF /PV MP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MOMFORINO WELL/ ❑ OTHER <br /> )� INSTALLATION 11CNN <br /> WELL SYSTEM REFAIR ❑ crtO89oECT REPAIR Cl VAPOR EXTRACTION WELL I <br /> C�R'/ I ❑N—❑RwIA, N.P. DEPTH PUMP BET/2-tFT. FIRST WATER LEVEL p <br /> HYPE OF PUMPI <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ BOIL BOIUNO R <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF CON/TRL/C TION/PECIFICAT IONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CAGING/BTEEL/PVC DIA.OF WELL CASINO p <br /> ❑ PVBUC/MUNICtPAt ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MOWTOFUNO GROUT SEAL PUMPED: ❑Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Ye. []NO S <br /> APPROX.DEPTH LOCKINO CHESTER BOX/STOVE PIPE S <br /> PROPOSED CON/TAVCTION/DPoLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULE/AND <br /> REOL/LATRONS OF THE SAN JOAGUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PER EORINANCE OF THE WOW FOR WHICH <br /> TMS PERMIT IS ISSUED,I SNALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPETI/ATION LAWS OF CALIFOFINIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERT THA7 RN E PERFORMANCE OF THE WORC FOR WNW"THIS PERMIT 1 89VED,1 SHALL EMPLOY PERSONS SUBJECT TO WORIOMAN'!COMPENSATION LAWS OF <br /> CALIFORNIA.' T C USE I HOUR IN ADVANCE FOR ALL REGUN1Eq IN/FI+C TTO L2WI�gyM22. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 919-0 x <br /> Det• �+ <br /> /LOT PLAN 0—to S-4.1 80.1. 'to <br /> 1. NAMES OF STREFTB OR ROADS NEAREST TO OR BOVNDINO THE PROPERTY. M. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> t. OUTLINE OF THE PROPERTY,GIVVM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM/. <br /> 3. DIMENSIONED OUTLINF/AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTTHM RAMS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,MNCLVDING COVERED AREAE SL/CH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROFERTY. <br /> .... :.... ;.... ' ...;.. ....... .... .... <br /> ... .. MAX <br /> .99 E a�T <br /> ......... <br /> .... .... <br /> w j <br /> z <br /> EtJV. � IrTrt I ' <br /> IR I Nh N H kEkE _l h JIV ISION <br /> ......... . l ` <br /> VS[ONLY <br /> t <br /> App11ae1bn Aeoepl.d BY ^DO. <br /> 6z <br /> G ( Arm I <br /> Oreo/bp-if—BY 0.1. P,—P I—p-11—BY —40 D.t. Cty <br /> DO.IGIellen ImPeatlen BY <br /> CemrtrorNe: <br /> ACCOUNTING ONLY: AID/ FACT <br /> P!CODES FEE INTO AMOUNT REMIT ED IEC !CASH RECEIVED■Y DATE PERMIT/SERVICE REQUEST NUMIER INVOICE <br /> 5� c O <br />