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APPLICATION FOR WELLIPUMP PERMIT I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RO,BOX 3188,9D4 EAST WEBER AVENUE,STOCKTON.CA 95201388 <br /> (2091490-3420 <br /> NON-REFUNDA LE PERMIT EXP?AES 1 EAS FROM DATE ISSUED <br /> ICOIRI 1 <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMTT TO CONSTRUCTANWOOq INSTALL THE WORK OESCRIBEU,THIS APPM <br /> JOAOUIN COUNTY DEVELOPMENT TITLEi,CHAPTER 9.111 5.3 AND THE STANDARDS Of BAN JOAOUIN COUNTY pUBUC HEALTH SERVICES,EN"R0 "TION IB MATE IN CoMPLL41NCE WRN AN <br /> M <br /> Joe ADDREBOR AP4T_ I f n NMEMA4 HEALTH DMBgN. <br /> f rsn (7�S4 �C <br /> OWNER'S NAME !^i r A.."„`_iTI C <br /> PARCEL B2FJAIN/ <br /> AOORESB ��(/? <br /> CONTRAO iOR_td �• L F11pNE114 _J� g� <br /> ADD/E88 4 �Q���� <br /> BUB CONTRACTOR �B� A—PHONE A1C��� <br /> ADDRESS 4I SIC 3131p.A.2v <br /> �/ <br /> PHONE <br /> P— <br /> TYPE OftiVQ1�PU/MP NFW WEtl ❑REPLACEMENT WELL ❑MOMTIMINO WELL <br /> M8T.VLATIONQ OTHE11_ <br /> Q WELL BYH7EM REPAIq ❑CRORS-CDNNECT-PA. ~` <br /> N—❑RgMr H-P.�� ❑VAPOR EKTAAC71pN yVEll.B � <br /> (TYPE OF PUMPI DEPTH RUMP 7ET/*7-R. FMIBT WATER LEVEL <br /> ❑OUT-0F-SW <br /> ERVICE ELL ❑GEOPHLL VBOCAL WE7 Q Bolt wfvm O <br /> EI DEeTIIUfCTION: <br /> INTCWjD-U4 <br /> �y <br /> CUNSTRUC ON FICATIONs <br /> ❑ <br /> INDUSTRIAL WOPEN BOTTOM q� <br /> % DIA.OF WELL�IIIFoss TK)N . -- f) <br /> DOMEBTICAYATE QORAVEL PACK/81Z6 TYPE OF CASINO/BTEEUPVCRXAOF CONTXUCTOR CASINO <br /> EE <br /> PUBUCAAUNICIPAL ❑DRIVEN DIA.Of WELL CASING D <br /> DEPTH OF GROUT BEAU f _ SPECIFICATION <br /> T❑MONTTTIONQ ❑OTHER GROUT SEAL RBTALLED BY/y t)ocI S _ GROUT BRAND NAME f^ <br /> lJ MONR OPoNO GROUT SEAL PUMPED:IRY- [IN. <br /> APPIOX.D9TN �/ CONCRETE PEOEST/y,BY DNLLE0.•❑V. ❑NO S r <br /> LOCKING CHESTER BO%fBTOVE PIPE_ <br /> PROPOSED CONSTRUUCiKINRBEALUNO METNOV, MUD ROTARYAUGER s }, <br /> AIR ROTARY CµlE--",r— <br /> OTHEq <br /> I HEREBY CERTIFY 7NAi 1 HAVE PREPAREO TH18 APPL1CATpN AND THAT THE WORK MALL BE DONE FI ACCORDANCE WRH SAN JOAOUIN COUNTY OMXNANCEB,STATE LAWS,AND Rip <br /> PEODU71oNe OF TIS SAN JOA NOT COUNTY. HOME OWNER OR LICENSED AGEKT•9 BIGNATURE CE11TIfIES 171E FOLLOWWG:'I CERTIFY THAT W nA PETFO RMANCE OF THE WAND RUL PIKFORW/eL17 <br /> i THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY <br /> PERSONS SUBJECT TO INO,rOAATI'e COM <br /> THE FOLLONnNG: 1 PB'HRTION LAWS OF CAI FUgNIA.' CONTM.CTOP'a HIRING OR BVe-CONTRACTING"E WoSIGNATURE CERTIFIES <br /> _ COCAN 7NAi M ALL 4 HOURS <br /> IN <br /> V THE WORK FOR WIACH THI/PERMET I8 ISSUED.I SHALL EMPLOY PfAsONS 8116JECT TO WO <br /> 9�,Id%NI�AN7 R/WT CALL IgIM IN ADVANC[FOR AL:.REOURED 0"I"WT)"AT f1�1 4M-1(227. COMPETE ONO ft C LOWER AREA PrROCgMK'6ESATIO/M LAWS OF <br /> GL)I _TIIIs��w A O.-A413/2"I <br /> n.y�Y3/2"7 <br /> PLO7 MN(0.—"S—*,Boal. <br /> 1.NAMES OF STREETS OR 110A09 NEA/!8T TO OR BOUNDING TRUE PROPERTY, <br /> 2.OUTLINE OF THE PROPERTY.GING DIMENSIONS AND NORTH DIRECTION. 4- LOCATION OF HOUSE SEWAGE DIBPOBAL SYSTEM OR FRDPOBED <br /> 5. DIMENSIONED OU/TUNFS AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF KWAOE OIevowa WmEMe. <br /> STRVCTURES,INCLUDING COVERED ASEA8 SUCH AS PATIOS,OWVEWAYS,AND WALKS. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> ON THE PROPERTy OR ADJOIN,,,pMpERTY. <br /> .. <br /> ..; .:.... a .. .... <br /> : <br /> A\ .. . <br /> .. ` <br /> ...; MAY 2.' <br /> i <br /> DEPARTMENT USE ONLY <br /> A"Ilpatbn A,epeptad By_ <br /> n.P.cnon ey� .�Liv <br /> Date Rim hupoeUpn B1 /` <br /> Dana <br /> Dslrue110n knpoellen'dy <br /> Dala <br /> CommnU: <br /> ACCO VN IN/G ONLY: AID& FACT <br /> P!CODES FFf INFO AMOUNT RDBTTEDNK ,CµN REC El BY <br /> I' DATE 1'EIBNITIs9lVICE gt'pl <br /> ry IC! <br />