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: APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAUUIN COUNTY PUBLIC HEALTH SERVICES <br /> 40) ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 389,446 N.SA; OAGUIN STS STOCKTON,CA 9624t"318 r <br /> (209)418.3420 <br /> r <br /> N9N•REFll1IBABlE PERM IT EXPIRES 1 YEAR FROM SAFE ISSUED <br /> ICSMPMIE IN TripliEBt&I <br /> AFKICATIoN IS HERE BY MADE TO THE CAN JDAUUIN COUNTY FOR A PEIWIIT TO CONSTRUC7 ANDMA INSTALL THE WORE bf SCRIpFO,THIS AAR)CATION 14 MAGE IN COMPLIANCE WITH SAN <br /> JOADUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.11-1J176.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTII OIV1610N, <br /> NTt <br /> JOp AHORI66AR ADN/ ��/Fa �1• �/ u�-� — CITY PARCEL SIifNAa <br /> OWNFR'S NAME C_+ je� (LCIS '' ADDRESS `.O ee z S D-s . .tL V nIDNF�.r/O ''^J�Z' 6Q Sn <br /> X59 /7 C(/Q'Y 11C/.T.ZZ/.ZSPIDNEFPWGZI-37VS <br /> CONTRACTOR �Y �ae&11774K/ ADDRESS r'Lr>1EaLU.f RIDNEI ff �E-FE ApoRESB - <br /> TYPE OF VKLLO'UMW ❑NEW WELL ❑REPLACEMENT WELL "4:N MOMTORNO WELL■ ❑OTHFR - y <br /> ❑1NSTAU.ATION ❑WELL.SYSTEM REPAIR i❑CROSS-CONNECTREPAIR ❑VAPOR EJTRACTI011 WELL F J <br /> ❑N—❑R .k N.p• DEPTH PUMP SET---". FIRST WATER LEVEL O <br /> (TYNE OF PUMP /A' ❑OUT-OF-BERME WELL 'j❑oFOPHY6UCAL WELL I ❑ 6 IL BG RIND S <br /> XDlurmjcmN' �ITr�A- ("TAAIT� ��./cu.S �.�E�A1-E'A la /'7e✓-� MaJ-.�` <br /> ILII ENOEO USF EYP&OF WFIL <br /> LOHSIRL'CTION SPECIFICATION& A <br /> ❑MbUBTRAL [3 OPEN BOTTOM DIA,OF WELL`1XCAVATN]N DIA.OF CONDUCTOR CASING O <br /> ❑DOMESTICNPRVATE ❑GRAVEL PAC%FSI2E TYPE OF CASIHOISTEEL VC DIA.OF WELL CA <br /> ❑PVSUClAEVNICIPAL ❑ORVEN DEPTN OF pRGUT SEAL SPECIFICATION = R <br /> ❑R-•R IRROATIONIAO ❑OTHER GROUT SFA6N6TAILEO BY F-T GROUT BRAND NAME �-7 I <br /> 0 MONTORNG OROUT 6EALPUMPED:❑Y.. 0N. CGNCpETEF4DEFTALBY0HA.LFiC❑Yw ❑N. 5 <br /> APPFIOX,BEPTH LOCKING CHESIER BOKISTOVE PEE $ <br /> FROPOLFD CONSTRVCIIONIptlWXO METHOD;MUD IKITARY Ain PATARY AUGER CABLE OTHER <br /> I `Y <br /> L HEREBY CERTIFY THAT I HAVE PREPARED THIS AIYIICATION AND THAT THE WORK WSLL RE DONE IN ACCORDANCE W1TI!SAN JOAALAN COUNTY ORDINANCES,STATE LAWS,AND RULES AND 5 <br /> 11EOVLAYIOHF OF TILE SAN JOA(KIIN COVNTY,HOME OWNER OR LICEHeED AGENT'S IBIONATURE CERTIFIER THE FOLLOWING;'1 CFRTNY THAT IN TI}E PFRFORMANCE OF THE WOM FOR WHICH <br /> REGULATIONS <br /> IS FTIREC JOAOUIALL EOUNTY.MOMRSO OWNER <br /> UCENSf MAX'F COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S IIIRNO OR SVS-CONTRACTINO SIGNATUIIE CTRTIFIESTHIS I <br /> 7NE TDLLOWINO: "I IFY THAT IN THE pFllFO E OF THE Wg1K FOR WHICH THIS PERMIT R IS6UEP,1 SHALL EMPLOY PERSONS SUBJECT TO WDRKMAN'S COMPENSATION LAWS OF <br /> CAUFORMA.' THE TCA • E., <br /> Alt R[G,ARED INSPECTION* <br /> AT 42UI IN3&2i.C MTi[TE DRAWING AT LOWER AMA PROM E'.T ,7,4 <br /> K TM._�ICDJ LT �trLk—UC7(S�—D.e. 17'G-? <br /> O/ <br /> PLOT MAN 10—S.5.0.1 Ib.l.^�-,• <br /> 1.NAME8 OF STREETB OR ROADS NFAPESY TO OR BOUNDING TISE PROPERTY. L,LOCATION OF HOUSE SEWAGE p[ei'OEAL SYSTEM OR PIIOPoBED �. <br /> i.OUTLINE OF THE PROPEFITY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DICPOSAL SYSTEMS. <br /> J.W1O <br /> MEN6NE0 OVTLINES AND LOCATION OF All EXISTING AND PROPOSED � 4.LOCATION OF WELLS WTNIR RADIUS OF ONE 11VNPREo FIFTY <br /> STFLUCTuREB.R{CLUINNO COVERED AREAS SUCH AS PATROB.DU1114WAYS,AND WALKS. ON THE PROPERTY OR <br /> ADJOINING lROPERIY. I <br /> ..,,.. ..... _ J <br /> : . : <br /> .. ... . . ...... <br /> .._ <br /> It <br /> PPo' <br /> f/ I� <br /> DEPARTMENT USE GNLY <br /> APPCuIbn ft-1.1 By� __ ___P.e. A"" 1 bu�!✓✓ ' <br /> DIeIA In P.cll.n SY D.1. PNnf iw-li.O BY DO. <br /> prlrusll.n 1rrp.cHan BY 0.1. <br /> �, .I.: �n 1-► !t !ct qk90332`fold No Nn6 5 .PI^tk 'fD SIYf M <br /> J <br /> ACCOUNTING ONLY: - ANON I� ii FACT <br /> PE COD" 11EINFO OUNT RFMLTTED CHECK/eDABH AEC13VED BY DATE PDPAITfSEAVICE REQUEST NLENSER INVOICE <br /> Z o 2 4650(c <br />