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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 /> s NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (CempI6t6 M TIlpIk*E61 <br /> APPLICATION 16 HEAE BY MADE TO THE CAN JOAQUIN COUNTY FOA A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DECCRI9ED.THIS APPLICATION 19 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT Trru.CHAPTER 9/-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH Df VISION. <br /> Joe AOOTEO$A)A AM#IL' 11 r' 1�J,�ozi jl I)FAJ;C 12 p✓E CITY 57%0(171J <br /> �'7 F w 1r PARCEL BIIE/ARII '- <br /> OWNER'S MAW �j 1 t t U L� �J 1 v L� ADONE66 ^�f'Fi ri'1"•. �11�'I':c o ;.l(1 p. c�-'��A`/PHONE(C A. <br /> coNTRAcrae Kit1LAaME6822 1 ). jrtlAi(FyJI IfOE:Iuct ""10C,t PHONE, .(r 3' <br /> .US CONTRACTOR AOORE6e �� MR PION(I <br /> PVF!OF WTLLP MP, Cl NEW L ❑MEPLACEMENT WELL ❑MONITORING WELL I Cl OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR Cl CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL F J <br /> ❑New❑ASP W H.P. DEPTH RUMP SET—". FIRST WATER LEVEL O <br /> R 1'PE OF RIMR <br /> ❑OVTdF-9EMVICE WELL ❑GEOPHYSICAL WELL I SOIL BORING ('-� a <br /> ❑DESTRUCTION! <br /> 1.11NDED Ust Ty"OF WQL CONSTRUCTION SPECIFICATION6 A <br /> Llff IRUOUSTRTIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION L/ DIA.OF CONOVCTOR CASINO O <br /> Cl DOMEI TIC/MIVATE ❑GRAVEL PACK/SIZE TYPE OF CASIN"TEEIIPVC DHA.OF WELL CASINO O <br /> Cl PUBLUCMMACNAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> 11 IMPT Lt N>•rr Tr-I <br /> pATgRR--yy -A A N/AO 1S10T1/ER R'� OK)VL SEAL INSTALLED BY OPgVT BRAND NAME it•'� �` 4S [ <br /> Cl MONTTOWNO OFEOUT*FAL PVNIKO:❑Y— ❑Na CONCRETE PEDEBYALBY DRILLER:❑Yr ❑IRT S <br /> APPRDX.OFT. �I-% LOCKING CHESTER SOX/STOVE PPE <br /> S <br /> PROW COMSTRIRCPOM/ LLUMO METHOD: MUD ROTARY AIR R OTAMY AUGER CABLE OTHER <br /> IMEREBY CERTIFY THAT I HAW PREPARED TMS APPLICATION AND THAT THE WORK WILL BE DONE MH ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND MUDS AN <br /> RFOULATIONS OF THE SAN"A COUNTY.HOME OWNER OR LICENSED ADEM'*SIONAEURE CERTIFIES THE FOLLOWING:'I CMTIFY THAT IN THE PERFORMANCE OF THE WORK FOR W N <br /> THIS PERMIT 161SSUED.1 T EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPMSATEOM LAWS OF CALUFORMA.'CONTRACTOR'S MR IN0 OR eUBCONTTIACTNO SIGNATURE CERTIFIES <br /> THE FOLLOWING: ".VldFM THAT M T AMC(OF THE W01K FOR WHICH THIS PERMIT M ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WMKMM'S COMRMSARON LAW*OF <br /> CALJFORMA.' THE APPY 1 T MUST C Illl6 IM AOVANCB FM AL1 REOU IR I)WSPWMNS AT fl l AqJ ".COMPLETE DRAWING AT LOWER AREA PROVIDED/ <br /> IV/GL i <br /> SIS.­S X Tine Dere <br /> ROT RAM 0—Ie S".e Sade <br /> 1.NAME.OFTITER*OM ROADS NEATEST TO M BOLUFAMO THE PROPERTY. S. LOCATION OF MUSE 6EW'AGE DISPOSAL SYSTEM OR P DMOTO <br /> !.OUTLINE OF THE PROPERTY.OFVMq DMENSON6 AND NORTH DIFECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> !.DWWNSRDNED OVTL/NFS AND LOCATION OF ALL EXWrING AND PR SEO S.LOCATION OF WELLS WTFMN RALMVS OF ONE HVHORED FNTY ET. <br /> STRUCTUREB,NCLUDINO COVEMED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WARS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> s <br /> I 3 i t <br /> z <br /> :LU r <br /> \.1 w � ` .L <br /> PAYMENT � s CZ <br /> cn ¢xEd^ �`.^ED t � <br /> DEC 71� <br /> v ' <br /> tr � �h1tl Joaouuv cu,x.TY <br /> r, PUBIC nEA:.'TH 64F lg j Q <br /> tt1V ENVIRONMEIRA.L HdALTH BIVI{WN <br /> USE ONLY / (/ <br /> �. nePNcNbn AeeePred er �-l� `i " "` 1��`C!`-''\` _D.e /� � � wee �• <br /> GreVt Meeo�lar.ST O. WPP Inevecllen Br D.e <br /> Orr..cllen Ir�Pecrbn Rl _Dere <br /> Cem-. <br /> ACCDUNr .ONLY: NDJ FACE <br /> P[CODFA FEE INFO AMOVNT MCI..TED CHEC /CASA ETEC a OATS I6PFITRSFAVICE REOIUEST NUMSNR INVOICE <br /> A <br />