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APPLICATION FOR 160ELL/PUMP PERMIT �i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 1 (209) 468.9420 $ LLL' k NON-REFUNDABLE PERMIT EXPIRES 1 YEpN FROM DATE ISSUED (Complete In TrlpRntBl / APPLICATION 1811ERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PENH RT TO CONSTRUCT MANOR INSTAL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOFmENT TR(•IS,C+NA'PTEII B{•.1116.JtAN{D THE STANDARDS Of BIW JOAWm COUHIY RIBUC HEALTH BENVICEB.ETMRONMENTAL HEALTH OMBpN. J08 AODRESSIOR A[PHI__Z�T%'t S JJTT IA IN i t Y 3 1 . CRY S Cttoo k 1-o Yt PM a 812F/APHf pp Q OYVNER'R NAME._ JR4% TQ A VA i" ' Co,A YY Vy ADDRESS 222 L• IN-06 zt-. 6"4 F 12 O f P10NE I T b D� 89�Q �. CONTRACTOR TLP% P"V 1r ON 4M PN ['q ( AODAESB UC/_68386S .., 361_ S 3 SU8 CONTRACTOR AODIEBBG 5-�:f 399226 UCS PNOHEI 1�`1 1 TYPE OF WEU PUMP•. ❑ NEW WELL ❑ REMCEMENr WELL ❑ weirommO WELL I ❑ OTHER I TFFirrr ❑ mBrAEUTTON ❑ WEu worm REPAIR ❑ cROBBCoNNECT REPAm ❑ VALOR EXTMCTRIN WELL P J 1 ❑N 0nweJ, N.P. DEPTH PUMP SET_FT. FIRI f WATER LEVEL O RYPE OF MMPI 11 ❑ OUT-0FRERVICE WELL ❑ OEOPNYRgIV.WELL I - BOR BORING D YG DLT B ❑DERRmCTrom F' INTENDED UBE TYPE OF WELL CONSTRUCTION SPECMAT10NI I n A L ❑ INDUSTRIAL ❑OPEN BOTTOM GIA.OF WELL EJtCAVATNIN M&OF CONDUCTOR CARING O ❑ DOMEBTIOMOVATE ❑0j1AVEL PACRIRRE TYPE OF CASIMMTEFVPVCNFT INA.OF WELL CASING `� O i 13 PUBIIC/MUNICNAL DRIVUT RE EN DEPTH OF GROW 1•T O L31F rc rr'1 BPECIFlCATION R �( ❑ BOBOATIOHIAG ❑OTHER GROUT BFK INSTATED EY SLI Y r GROVE BRAND NAME E ,d' ❑ MONRORIHG GRDUT SEAL PIILIPED: Vs ❑Ne CONCRETE PEDEBfAL BY DRILLER❑V. ❑Ne s APPRON.OEPr" LOCRINO CNEErEn BOXISTOVE PIPE F i NmmMB CONRl11VCTONgMIIMO METHOD: MUD ROTARY AIR ROTARI AUMR CABLE OTHER v `0 MQ PB 1 1 111Y' I HERBY CERTIFY THAT I HAVE PREPARED THIS APPUCATpH AND THAT THE WOW WILL A DONE m AC IS THE O WRH BAH"AWN COUNFY HE P%R RMESTATE THE AND MR AND RI!OUTAYIONB OF THE BAN JOAOUM COUNTY. NOW OWNER OR LIOENBPo AGENT'S SIGNATURE CFAPIFIEB THE PoLLOWING:'I CERTIFY THAT m THE PEIRORIAANCE OF THE WONL FOR WHICH THIS PERMR IB ISSUED,1 04ALL NOT EMPLOY FERSONS SUR.IECT TO WOMBMAN'S COMIFNSATON LAWS OF CAUFORHIA.' CONTRACTORS HIRING OR SUBCONTMCTRIG SIONATURE CMIFIES 1E... THE FGLLONTNO: •1 CERTUY iNAr M THE iFIVORMANCE OF THE WORK Pon WHOM THIS FEIB.IIT 18188VPo,1811ALL FANAAY I4RBONB eVSJECT Po W011rBMAN'S COMISNSATON UWB OF LCAUFOWGA.• THS APPLICANT MUBT CALL M HOW IN ADVANCE FOR ALL REO PISI AMMINI AT 1208)441040422. COMPLETE DRAWING AT LOWE11 AREA R(ONOEO. T ei N E c /�� TRI. $Q � `T O J 1 t 91519-1. Iy �-+ PLOT FLAN M.W INNN SvHR •I41 1 r. 1. NAMES Of STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTYC LOCATION OF MUM SEWAGE DISPOSAL SYSTEM OR PRmOBED L 2. OUTU IF OF THE ROPEIRY.OINNO DISIENWNS AND NORTH DIRECTION. MA "OF SEWAGE DISPOSAL BYSFFMO. 2. DIMENSIONED OUrLIHEB ANO LOCATION OF ALL E)IMrINO AND PROPOSED t.UO TON OF WELLS YRTTIIrI RAORNPOF ONE HUNDRED FIFTY FT. SfPUC1VRE8.INCLUDING COVERED AREAS SUCH N PATIOS,DINFWAYS,AND WAILS. ON TATE PROPERTY OR ADJORANG FMIRITITY. L . OEPAIRMOFT MR ONLY J. 1 AeISv4llen Aaa.vlad Br LaaA bPwna.er wl. wl�e we�B..sr D'r' D..Iwaen hRP.Nbn er DNR I CevnmPRr• r ACcom FACS maa ONLY, AIO/ PE coon FEEINFO AMOW REMtrim CHECKIgAeN RECBVED er DATE P TISE E mmmr NUHRDI INVOICE L PUE.Heats Sam.-ETNim.173(1/97)