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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> \ ENVIRONMENTAL HEALTH DIVISION bVtA. <br /> 1 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> Rw S <br /> NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICampiete In Tripfketel - a• s�cA.j,K.l.•c'�� <br /> APPLICATION 08 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE N DOMPLLANCE WRIT BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.3 PND THE STAN ARD*OF SAN JOAQ*COU� NM /ERVICE9,ENVIRDNMENTAL HEALTH DMMON. <br /> JOB ACORESSIOR A PARCEL BIiE/ARIIq.,f'J C+ RgNE/7SPr'SS �AV AL2 P� ` <br /> CONTRACTORfVlWC IK ADDFIEUC/,�</62z pIpNEPAM CONTRACTOR ADUTIMe PHONE <br /> TYPE OF W'ELLJPUMP: IrI—WELL ❑ RE"CEMEMT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRI188LONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ✓ <br /> ❑Nwv❑RSRW M.P. DEPTH RUMP BFT_FT. FIRST WATER LEVEL O <br /> (TYPE OF RUMP) <br /> ❑ OWOP-SERVICE WELL ❑ GEOPIYBICAL WELL/ ❑ SO&BORING S <br /> ❑DEDRUCTION. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION � DIA.OF CONDUCTOR CASINO D <br /> ❑ <br /> �DOMfBTICIPW VATf 1 Yl GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA,OF WELL CASINGy— D <br /> 11RRLUC/MUNICIPAL �❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION _ R <br /> 11IRRIOATION/AO ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME ✓tom E <br /> ❑ MOMTORNG /-1, GROUT BEA` !NESTER S <br /> PUMPED! <br /> [IN. <br /> BIOVE DIRE PEDESTAL STAL B mum:11Y.� S <br /> APPROX. OFFTH C/// <br /> PROPOSED COMS1RIIOl10N/DNWNO METHOD: MUD ROTA- CK ^AIR ROTARY AUOEfl CABLE OTHER <br /> I HEV"Y CERTIFY THAT I HAW PREPAPED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCOMAHCF WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAW8,AND RULER ANO <br /> MOUTATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOEW'B SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,1 MULL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPIDISATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB{OWRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 181BSUED.1 SMALL EMPLOY PERSONS SUWFCT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORIAA' 111E APPLI/CCAN�RT MUST CAM <br /> USTCALL t MMY IM ADVANCE FOR ALL RFOWFD.111�N\SPRAO/(N1nAT KtOS11q-M]f. COMPETE dV1MN0 AT LOWER AREA PROVIDED. <br /> ll'r X {.i I lWK' ��y/ TINS JP iC 4'IC{� ON.eI? <br /> PLOT PLAN 0—le B W.l BeHn 'IB <br /> 1. NAMES OF STRET8 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SFWAOE DISPOSAL SYSTEM OR RoPoSfO <br /> S. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OWLNFS AND LOCATION Of ALL EXISTn AND PROPOSED S. LOCATION Of WELLS WTTMN RADIUS OF ONE HUNOMD FIFTY R. <br /> STRR;TUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRVEWAY8,AND WALKS. ON THE PROPERTY OR ADJOINNO PROPERTY. <br /> �ro�plc � <br /> �A <br /> h <br /> �? P NT <br /> L <br /> RE Vr-T-1 <br /> 5AN JUAUUJN U( <br /> ' PUBLIC HEALTH ,- <br /> ENV)AQNMENIAl)•k T:.; _, II <br /> /1 •_ _. _ Dssumsrlr ueF o1Oi— >,. <br />