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APPLICATION FOR WELL/PUMP PER <br /> SAMbAGUIN COUNTY PUBLIC HEALTH SE ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TrlpReetel <br /> ALL THE WOW <br /> JAPPLICATION OAQUIN CUIS HERE BY MADE TO NTY DEVELOPMENT TTHE SAN JOAQUIN COUNTY FOR A IRE.CHAPTER 8-1115.8 AND THE STANIT TO CONSTRUCT AND/OR DARDS OF SAN"AMIN CIOUTN-�T.�Y.�PU.-�BL�,IIC HEEAA THS SERVICES,ENVIRONMENTAL HEALIS APPLICATION Is TH(DIVISION.ANCE WITII BAN <br /> JOB ADDRESB/OR APNR 2.3 - 190- 01 CRY CtS V r"TS PARCEL SIZE/APN! <br /> IIC�r� ��,/s c�,�� �1 oe"vT (W PHONE( I s s <br /> OWNER'S NAME I�r-G' �f�1Y � ADORE88 A" Z Sly sm. (4�) 88z <br /> QL.I C00:4 C0451�1LTAklrP , RNG. ADDRESS S_R 4¢I�� UCR RIONE! _ <br /> collrlacioR W"°+ P.o. �X 507 2VRpr 4L5 <br /> BUB CONTRACTOR �IT�(L VRaLU�G 4- ADDRESS <br /> UCI��6J PNONE!_ Ong <br /> TYPE OF WELIJPUMP: 11NEW WELL ❑ REFLACEMENT WELL ❑ MONITORING WELL! ❑ OTHER <br /> J <br /> ❑ INSTALLATION WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAFR EXTRACTION WELL! G <br /> [INE ❑ReP.lr H.P. DEPTH PUMP SET---FT- FIRST WATER LEVEL _p� _ <br /> 2�/jR $V'� <br /> ROPE-OFPUMP( BOIL BORING 8'FJYIacw. a <br /> // <br /> ❑ OUf-OF-BERVICE WELL ❑ GEORIYBICAL WELL <br /> .UEBTRUCTION: C"Fk4 A P -� T <br /> 1 w LL <br /> A <br /> INTFNO-0 USE TYPE OF WELL CONSTRUCTION SPFCIFICATIONe <br /> GIA.OF CONDUCTOR CASINO <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM GIA,OF WELL E%LAVATION <br /> O <br /> ❑ pOMESTRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINORiTEEI/P•JL <br /> CIA.OF WELL CASINO D <br /> ICM1' <br /> 1 DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ PUBLICIMUNICIPAI ❑DRVEN gwyle0o GROW BRAND NAME E <br /> ❑ IRRIGATIONIAG 90THERf (`illi*0R1401) GROUT SEAL INSTALLED BV <br /> GROUT SEAL PUMPEO:Ely. ❑Ne CONCRETE PEDESTAL BY DRIUER:❑YM [IN. S <br /> ❑ MONITORING �� S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE <br /> AUGER CABLE OTHER <br /> PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY. AIR ROTARY <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARI:D THIS APPLICATION AND THAT THE WORL WILL BE DONE IN ACCORDANCE WITH BAN JOAODi;COUNTY OPDINANCEB,STATE LAWS.AND RULES ANO <br /> REGULATIONS OF THE BAN JOAOVIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS THE F PERMIT Is INO:SUED,I WALL NOT EMPLOY FOFRMANUBJECT TO WORMAN'S CE CE THE WOR(FOR WHICH COMTHIS PERMIT IS ISSUED,SATION LAWS OF ,IIBH LLL EMPLOY PERSONS SUA.- CONTRACTOR-9 IBJECT TO WOR MARING OR �COMPENSATION LAWSTING SIGNATURE OF <br /> CALIFORNIA.' HE A CANT UST A 34 MGM$IN ADVANCE FOR ALL REQUIRED INSp 11DONS AT 12")4eS COMPLETE DRAWING AT LOWER DREA PROVIM. DED. <br /> TIO. '��PrYYNF JJ <br /> Ble^.1% <br /> not FLAN 101.w 1-Betel S -I- le <br /> 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> I. NAME@ OF STREETS OR RO a NEARE700,_ <br /> OUNDING THE PROPERTY. EXPANSION OF BEWAGE DISPOSAL SYSTEMS. <br /> Z. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNURED FIFTY <br /> 3. DIMENSIONED OUTUNF.S AND LOCATION OF ALL EXIBTINO AND PROPOSED ON THE PNOPERTY OR ADJOINING PROPERTY. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. <br /> P Ste- F(dFui� 1 IAtc LnnEn HJ soles SA44f OOrl ,AND Q4ky!!w- P 1' <br /> i <br /> -_ <br /> DEPARTMENT USE ONLY J A ^ <br />