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APPLICATION FOR WELL/PUMP PERMIT i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .-L, f FI <br /> ENVIRONMENTAL HEALTH DIVISION ; 1; <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Camplela In TrlpReatal <br /> APPLICATION la HERE BY MADE TO THE RAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WONSE DESCRIBED.THIS APPLICATION IR MADE IN COMPLIANCE WRIT BAN <br /> JOAQUIN COUNTY DEVELOPMENT <br /> TITLE,CHAPTER 8.1115.3 LAND THE STANDARDS)OF BAN JOAQUIN COUNTY PUBLIC HEALTH SEFIVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> AUOREBSIOR APHS .7 I !( F �'�/'�C 7 7`JL n 1.�.? CITY <br /> 13", S rPyy PARCEL 81ZFJAPN/2S/o- 0 <br /> 80-2-t <br /> E <br /> OWNEMSNAMEeTFr " UJ'tADO/E88�o OD� .(-7 PHO <br /> U <br /> / L �"y374-43U <br /> CONI RACTOa001 1,11ADDRESS p Ok 3y UDNE <br /> 1 <br /> RUB CONTRACTOR �p1 ADDRESS 4A,-7, <br /> 1�t �] LICS PHONE <br /> TYPE OF WELUPUMP: ❑NEW WELL ClTO <br /> REPLACEMENT WELL pi MONIRINO WELL/ �q ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CR08R.COWACT REPAIR ❑VAPOR EXTRACTION WELL E J <br /> Cl NPM❑R.P.I1 H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O <br /> R YPE OF RUMP <br /> ❑OVT OF-BERVOE WELL ❑GEOPHYSICAL WELL I ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> IN TOROM USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 �� A <br /> ❑INDUSTRIAL El OPEN BOTTOM /(J DIA.OF WELL EXCAVATION L OIA.OF CONDUC TOR CA81NO O <br /> ❑DOME811CIP NATE J�OMVEL PACXIMZE ✓ f TYPE OF CABING/BT EEI/PJC '( yI �0 y- DIA.OF WELL CASINO 7— O <br /> ❑RINIICIMUFMIPAL ❑DRIVEN DEPTH OF GROUT REAL � SPECIFICATION SC/' 4-- <br /> 11 <br /> q <br /> ❑IRIaGATION/AG Cl OTHER GROUT SEAL INSTALLED BY f OWITr BRAND NAME �Il,rlGr E <br /> )w MONHORINO GROUT SEAL PUMPED:J4— ❑No CONCRETE PEDESTAL BY OFOLLER:LEIyyU.YM ❑Ne S <br /> APPROX,OpIH 2 G �e It LOCKR/O CNF8TM BOXRFMVE PPF. S <br /> PROPOSED CONSTRUCTIONIDIaLUNO METHOD: MUD NOTARY AIR ROTARY AUGER CABLE OTHER <br /> I"I NY CERTIFY THAT I HAVE PNEPARM THIS APPLICATION ANO THAT THE WOFW WILL BE DONE M ACCORDANCE WITH/SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAOUN COUNTY.HOME OWNER OR LICENSED AGENT'S RIONATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE WON(FOR WHICH <br /> THBR PC—IT M t88UED,1 SIAL NOT EMPOY PERBON8 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALRORMIA.'CONTNIACMR'S MEtlNO OR SUBLON"FRACTING SRINATURE CERTIFR■ <br /> THE FOLLOWING: 'I CET HAT ON THE PERFORMANCE OF THE WORK FOR W10CH THIN PERMTi IR ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA." TL/EATUC MUST CALL 24 NOUNI IN ADVANCE FOR ALL REQUIRED INSPCCT/[I a AiYIZORI 4441-1E22.COMPETE DRAWING AT LOWER AREA PO DEO. <br /> Nlpwd X '`] NII. On. <br /> ROT PIAN Idw Ie ee.lel Ne.l. le <br /> 1.NAMEN OF 8/REFTS OR/GADS NEAREST TO OR ROUNDIN I TNM PROPERTY. S.LOCATION OF HOUSE RFWAOE DISPOSAL SYSTEM OR POPOSEU <br /> Z.OUPLME Of TIE PROPERTY,01VRNG OIMENNONR AND NORTH DIRECTION. EXPANSION OF SfWAOE DISPOSAL SYSTEMS. <br /> J.DIMFNSONEO OUIUNES AND IOCATON Of ALL EXINTOM AND PEOPORED a.LOCATION OF WELLS WITTSN MONS OF ONE HUNDRED FIFTY P. <br /> MT TU Ee,INCLUDINO COVERED AWAN SUCH AN PATIOS,DRIVEWAYS,AND WAMS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> :. <br /> • OFFAATMENT USE ONLY <br /> APFRenlen A~,d BY p DMS l O r u A.r <br /> G1eul Impeellen B. D.I. �� (l Puns IrwpRelen eY o.R. <br /> G..nlan.l.11wlecllerP e. o.IA <br /> ceml..elw.� <br /> ACCGUNHNG ONLY: AHO/ FACF <br /> P[CO/O�S/1 '-DMO AMOUNT REMITTED CHECKFtCANH RECEIVED NY DATE {� ►9aWT/SERVICE MOUERT NUMNFR INVOICE <br />