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F <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> r ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST.STOCKTON,CA 95201.388 <br /> (209)4853420 <br /> NOWREFUNOASLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICempNp in TrglicatEl <br /> f APPUCAMN IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FORA P IT TO CONSTRUCT AND/OR INSTALL THE WORD(DFWP4BED,THIS APPUCATWNIB MADE LN COMflJ E NRrH SAN <br /> e I JOAGUIN COUNTY DEVELOPMENT TRIS,CHAPTER 9-1115,3 AND THE STANDAROS OF SAN JOAOUIN COUNTY FVBUC HEALTH SMVICE6,ENVIRGNMENTAL HEALTN DIVISION. <br />�I L dire e! JOB ADDRES6,OR APNA 11en+gv.Aj'p- s7y—&fD cm - -+✓ <br /> �[ PARCEL BRE/APN* <br /> owNER's NAmE_.Lf,f],EF6G l-f C_Wl 1 SR&S, _. ADDRESS -(QT /UJ~GRY <br /> C <br /> PHONE R <br /> CONTRALTO (40 ` ADDRESS U C r LICR�Q� 3 PHONFI 7(�+1Tt /7 <br /> I <br /> Fl! <br /> sun cONrRhcront-I5-n-yfrZrUl ONE 0 <br /> TYPEOFWD-IJFUMF: ❑NEWWELL Q REPLACEMENT WELL 0 MONRONNOWELL* ❑OTHER <br /> e n/ ❑INST�A41�KNON ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR 13VAPOR EXTRACTION WELL I J <br /> SuBrn SBSIQ/E ❑HFR�I aP.r H.P. RUMP SET4_Fl, FIRST WATER LEVE-sk— O <br /> �r�jj{TYPE OF RUM% <br /> ILe=pl/i�4 ate./S7��J �� ❑OUT-O.RVI.E WELL ❑OEOPHYSICAL WELL 0— ❑ SOIL MONO <br /> ` 9 <br /> F+ ❑ <br /> DESTRUCTION' <br /> INTFnCEe Ucf TYPE OF WELL CDNRFC <br /> FTRDCON BPIpc1TIOryc A C[y. <br /> ❑WDIUSTRLLL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D v <br /> r ll-,YDO/ME671CMUVATE ❑CRAVEL PACKISRE TYPE OF CASINGISTEEL P DIA.OF WELL CASINO D <br /> Q PIUSUCfMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEµ SPECIFICATION A <br /> Q IPogGAT10WMi ❑OTHER GROUT$EµINSTAL D BY GROVE BRAND NAME f''t E <br /> [3MONROmNG GROUT SEAL PUMPED-13 Y- ❑N. CONFAETE PEDESfµBY ORLLFTI Q Vr ❑N. S <br /> A`—.DEPTH LACKING GH—M BOX—VE Rf4 s <br /> PROPOSED CON&MUCTIONtMUUNC METHOD:MUD ROTAIIY AIR AVTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE FRWAREO THIS APPLICATION AND THAT THE WOR[WILL BE DONE IN ACCORDANCE WITH SAN JOA W COUNTY ORDINANCES,STATE LAWS.AND RIMES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOMFOWNER Oq UGENBW AGENT'8 SIGNATURE CFRrNIE6 THE FOiiAWIND:'I CERTIFY THAT IN THE PEAMAMANCE OFTHE WORK FOR WHICH <br /> THIS PERMIT 16 ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECTTO WORIQAAN'S COMFFJNiATIDN LAWS OFCAUFORNIA.-COHTRALTOA'S HIRING ORSUSCONTRACTING SIGNATURE CERTWES I� <br /> THE FOLLOWMr -!CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TTSS PERMIT 16 IBWED,I GHALL FMPUQY PEF:60N6 SUBJECT TO WORKMAN'S COMPV4*A ON LAWS OF I <br /> ' CAUMANIA.' VST CALL 34 H0=ALL REQUIRED INSPECTI T IS *4 c M� OWIWING AT LOWER AREA PROVUDED. <br /> Tit. <br /> HRT FERN lor.w m eF.l.1 8uN <br /> i.NAMES OF STREETS on ROADS NEARFST TO OR SOUNIXNO THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR FROPOSEO <br /> 3.OUTUNIF OF THE PROPERTY,GIVING NMENSIONB AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 5.LOCATION OF WELLS 4NTHIN N a UB OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES INCLUDING COVERED AREAS SUCH A6 PATIOS,DRIVEWAYS AND WALKS <br /> (((t PROPERTY OR ADJOINING PFWPDTTY. <br /> .................... <br /> E9 <br /> psr <br /> F .......................... ...... <br /> ........ ........... <br /> .......... ..................... <br /> ................. ...... ... <br /> �YP�AtNi <br /> C <br /> . <br /> .......... <br /> .... <br /> stpil <br /> 3 9995 <br /> SRI�aaQu1 u co <br /> ._s__ ....,. .. �EH oN - <br /> D e .. <br /> PDR. <br /> EPAPIM T USE ONLY <br /> EN <br /> Aee.p[tl BY <br /> E j Grout IIrIWNon By D.m ARP IIrP�enn BYE -`1"eL'-� - o.I. ! 4� <br /> Ij1EE De.numwn I..P.�lon ar D.w <br /> ACCOUNTING ONLY: NDI FAC <br /> }} * <br /> 9 PE Coen FEE— AMOUNT nBAITIITTE�ID\lNEC��ry �7 - DATE� <br /> D a �I� � PCR16IMcewICE REQV TNUMBER ..E <br /> {arF`�d 1 <br /> F , <br /> Fj <br />