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0 <br />n <br />n <br />����-� � DEPARTMENT USE ONLY <br />t <br />APpilaell- Ac—tdBy � Oele_!___j_1. <br />aalA kNPWlb,1 Ey oe/e PVms t-0-1—er �T�T� On. <br />0-1-0- 4NPealim, Ey Dale <br />ACCOUNTING ONLY: <br />eINTENOEO USE ITPE OF WELL CONSTRUCTION SPECIFlCA 10 If . A <br />. <br />- ❑ INOUBTRIAL ❑OPEN BOTTOM ORA. OF WELL EXCAVATION DIA. OF CONDUCTOR CABINO 0 <br />❑ DOMESTICIPPoVATE ❑ GRAVEL PACK/GRE TYPE OF CASINOISTEEUPVC C DIA. Of WELL CASINO l t 0 <br />FE CODES FEE INFO I AMOUNT..TIED <br />❑ PUBUCIMUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br />APPLICATION FOR WELLJP ERMIT <br />❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br />PEIS.OTISERVICE REOUSST NUM/ER INVOICE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />;'aa�� <br />APPROX. DEPTH LOCKING CHESTER SOXAITOVE RPE S <br />ENVIRONMENTAL HEALTH DIVISION <br />PROPOSED/DPoU1NC METHOD: MUD ROTARY AIR R�OLTARY AUGER CAt7LE OTHER <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />I HE WaY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 8E DONE ACCORDANCE MTN BAN JOAQUIN COUNTY ORDINANCES. RATE LAWS. AND RULES AND <br />(209) 468-3420 <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIONATUIE CERTIFNS THE FOLLOWING, '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />11011•REFUXUABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 20 Jul 1 W 6 <br />THE FOLLOWING: ' 1 CERTIFY THAT Tiff P4ER,(F,O�RMANCE OF THE WORK FOR WHICH THIS PEMIR 18 ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN -6 COMPENSATION LAWS Of <br />(Complete In TrlpRata) <br />CALIFORNIA.' THEA CANT MU CALL IN ADVANCE FOR ALL REQUIRED lB tNtCTONB AT//130e) 408-3(422. COMPLETE DRAWING AT LOWER AREA PLO p <br />I� j <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WORK DESCRIBED. T168 APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br />( LIS" 4 7' J / <br />Sipped X TINe C Ome <br />JOAOUM COUNTY DEVELOPMENT TITLE, CHAPTER 9.1 115.3 AND THE PTO OF SAN JOAOUINCO NTY PVBt1C NEALTH/�SERVICES. ENVIRONMENTAL HEALTH DIVIISSIIO�N. <br />JOB ADORESSMR APNf / �S 1� 71I�I 6 <br />PLOT PLAN 10— le SeNel Basle ' Ie <br />OWNER'S NAME1++W/VA,,p <br />_ CIry �PARCEL SIZE/APM8 <br />.�4AfO PA 3•j bzq <br />It L �e �t:ZJ � - PHONE <br />CONTRACTOR <br />l� r <br />ADDRESS ?—C?6f.. L�'j'LS���.ry,��^/�UCS PHONE If <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITIAN RADIUS OF ONE HUNDRED FIFTY FT. <br />!!//I <br />euBCONTRACTOR .�lpCifVNe <br />�I�IJATi <br />ADDREB,;7107t%15F�I/VML'N,I.y/W ALR:B�6r zde PHONEf,Y�5--67{� <br />. TYPE OF WELUPUMPt ❑ NEW WELL <br />❑ REPLACEMENT WELL ❑ MONITORING WELL f ❑ OTHER <br />❑ INSTALLATION <br />❑ WELL SYSTEM REPAIR ❑ CROBBCONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J <br />❑ New ❑ Reesll <br />H.P. DEPTH PUMP SET _F r. FIRST WATER LEVEL O <br />(TYPE OF RIM% <br />A . <br />❑ OVT-OFBERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING g <br />0 <br />n <br />n <br />����-� � DEPARTMENT USE ONLY <br />t <br />APpilaell- Ac—tdBy � Oele_!___j_1. <br />aalA kNPWlb,1 Ey oe/e PVms t-0-1—er �T�T� On. <br />0-1-0- 4NPealim, Ey Dale <br />ACCOUNTING ONLY: <br />eINTENOEO USE ITPE OF WELL CONSTRUCTION SPECIFlCA 10 If . A <br />. <br />- ❑ INOUBTRIAL ❑OPEN BOTTOM ORA. OF WELL EXCAVATION DIA. OF CONDUCTOR CABINO 0 <br />❑ DOMESTICIPPoVATE ❑ GRAVEL PACK/GRE TYPE OF CASINOISTEEUPVC C DIA. Of WELL CASINO l t 0 <br />FE CODES FEE INFO I AMOUNT..TIED <br />❑ PUBUCIMUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br />RECSIVE0 BY <br />❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br />PEIS.OTISERVICE REOUSST NUM/ER INVOICE <br />-I'IIWOATION/A0 <br />�0 <br />MOMTOPoNO GROUT REAL PUMPEO: ❑ Yw ON. CONCRETE PEDESTAL BY DRILLER; ❑ Yw ON. $ <br />;'aa�� <br />APPROX. DEPTH LOCKING CHESTER SOXAITOVE RPE S <br />�k1` <br />PROPOSED/DPoU1NC METHOD: MUD ROTARY AIR R�OLTARY AUGER CAt7LE OTHER <br />h/L}wA% N( 0.l 4 VT!f Al 1 c Ivy$ F <br />I HE WaY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 8E DONE ACCORDANCE MTN BAN JOAQUIN COUNTY ORDINANCES. RATE LAWS. AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIONATUIE CERTIFNS THE FOLLOWING, '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMITR ISBUEO, I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORJIA.- CONTRACTOR'S "WHO OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' 1 CERTIFY THAT Tiff P4ER,(F,O�RMANCE OF THE WORK FOR WHICH THIS PEMIR 18 ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN -6 COMPENSATION LAWS Of <br />CALIFORNIA.' THEA CANT MU CALL IN ADVANCE FOR ALL REQUIRED lB tNtCTONB AT//130e) 408-3(422. COMPLETE DRAWING AT LOWER AREA PLO p <br />I� j <br />( LIS" 4 7' J / <br />Sipped X TINe C Ome <br />PLOT PLAN 10— le SeNel Basle ' Ie <br />T. NAMES OF STREET$ OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />3. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL. SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITIAN RADIUS OF ONE HUNDRED FIFTY FT. <br />0 <br />n <br />n <br />����-� � DEPARTMENT USE ONLY <br />t <br />APpilaell- Ac—tdBy � Oele_!___j_1. <br />aalA kNPWlb,1 Ey oe/e PVms t-0-1—er �T�T� On. <br />0-1-0- 4NPealim, Ey Dale <br />ACCOUNTING ONLY: <br />FE CODES FEE INFO I AMOUNT..TIED <br />( CNECK/ ABN <br />RECSIVE0 BY <br />DATE <br />PEIS.OTISERVICE REOUSST NUM/ER INVOICE <br />L} °° <br />;'aa�� <br />U'> <br />�k1` <br />1 <br />Pub Health Serv. • Enviro. 173 (1/97) <br />