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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 J <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICempletB M TripOBN.I <br /> APPLICATION IS HEM BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDrOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 81116.3 AND THE STANDA OF SAN"AMIN COUN�LtV�P'U1B1L/KJ/IIrE�ALT4 SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JON AODRESWR All -700 IF' k07?i 90AD CAppj CRV LIE' ,fl�C E`1M/J�, pp�� PAMELL SIZVAPNI <br /> OWNER-8 NAMEI/rISW5L �•4CTMc_5AGErjcq(5I4ARVF 1�Fe1'X AMSE1B7yo EI 4cm QQ1AD T51-D6, S/ )0O� RpNEI SZ-zo 93 \ <br /> COMPACTOR KA t);A4 ItJ ff K>A,gL AODREeeloN9 aDPLACrki ri-c}if RD: PHOONE9 �� 1 <br /> SVB CONTMCTOP " ""'�- U*Lr q"�Y1"L� ADORERS L� 1 1 UCEO's 33 " HONE/ <br /> TYPE OF WELL/PUMP. IE0R NEW WELL ❑ REPLACEMENT WELL 1p MONILONNO N/E-05) C,1) ❑ OTHER EXTRACTION WELL I J <br /> By INSTALLATION ❑ WELL SYSTEM REPAIR ❑ C e` OONINNNEC-T RAW"AVAPOR <br /> ®New❑IYpM, N.P. DEPTH NMP SET_". FIRST WATER LEVEL O <br /> (TYPE OF MMPI <br /> ❑ OUT-0E-SERVICE WELL ❑ OEORIV6IUL WFLL I ❑ f1011 BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> 11 INDUSTRIAL ❑t�}OPEN BOTTOM DIA.OF WELL EXCAVATION HQ� Io-I2,1 DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTK:RRSVATE (tl ORAWL PACK/SIZE I TYPE OF CASINO/STEELS//VA�C ,,KK�.1ff �O ,,/�,�L DIA.OF MLL CAMNG I�rI 0 <br /> ❑ NBUCIMUNICIPAL ❑DRIVEN / DEPTH OF GROUT SEAL.•JAF/F1�C 1D IW C SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTAU-VOS MRY PPOLL4Z BMW BMW NAME E <br /> 54 MONIMAING i `� BMW BEAT NMPEO: py Yr [IN. ` CONCRETE PEDESTAL BY DRLLER:❑Yw [IN. 5 <br /> APPROX.DEFTHV! 5O 1 75 140E)-00 LOCKING CHESTER BoXmow RPE YES 5 <br /> PROPOSED CONSTRUCTTON/DIULLNO METHOD: MUD NOTARY AIR NOTARY ✓ AUGER CABLE OTHER <br /> 1 llt ENY CERTIFY THAT I DAVE PREPARED THIS APPLICATION AND THAT THE WORK VRLL BE DONE N ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCE8.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT N THE PERFORMANCE Of THE WOR(FOR WHICH <br /> THIN PERMIT 18 ISSUED,1814AM NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAMORNIA.• CONTRACTOR'S HIRING Oq NR-CONTMCTNG SIGNATURE CERTIFIES <br /> THE FOLLOWIM: •1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 181NSUM.11YBNALL EMPLOY <br /> APERSONS <br /> MmIMECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORM^ Ike �� ANT MUSy CALL t �IM ADVANCE FOR ALL PEDLARED �DI�� ATI./LC� 5F"rN/ZGTCK AT LOWER ARE �OED.� <br /> qwq % /u/E LV/` K Tllb Deb <br /> ' R •b_ Allo-$57-7.�lit <br /> PLOT FUN 0.1e Saek1 Na.le <br /> 1. NAMES OF STREETS OR ROADS MEANEST TO OR BOUNDING THE PROPERTY. I. LOCATION OF SOUSE SEWAGE DISPOSAL SYSTEM OR PPOPOBED <br /> E. OUTLINE OF THE PROPERTY,OP NO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOBA SYSTEMS. <br /> 3. I MENSOWD OMMEB AND LOCATION OF ALL EXIS`NM AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED ASEAN SUCH AB PATIO#,DRIVEWAY$,AND WALKS. ON THE PROPERTY OR ADJONNG PROPERTY. <br /> SEG A7- acN� <br /> k;5 <br /> D <br /> IAW 5F7 <br /> ' RRAIZI� T <br /> I <br /> DEPARTMENT USE ONLY <br /> GreU K,eeeerlen Sy Dels Pune Imfeellen By D.I. <br /> D,wuOellen Imomlbn Br Dela <br /> CemmeMr <br /> ACCOUNTING ONLY: MDI FACS <br /> IE CODES FEE ISO AMOUNT REMITTED CNEL ASH RECDVED Sy DATE PFFWBTISMVICE REQUEST NUMBER INVOICE <br /> D..k Une1N,m.., -Pnvirn 171 11 roll <br />