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APPLICATION FOR WELLJPUNIP PERMIT <br />SAN JDAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 3M TA EAST WEBER AVENUE, STOCKTON, CA 952 i W <br />(7091469-3420 <br />NON REFUNOAOLE PERMIT EXPIRES I YEIR FROM DATE ISSUED <br />APPLICATION IS HERE BY MADE TO THE BAN JOAOUIN COUN7Y FOR A PERMIT TO COH,9 ntWT�I,NnIOReN6TALL 7HF. WOO( OF SCRIBED. TI118 APPLICATION IS MADE M COME. IANCE WITH SAN <br />JOAOUM COLwrY DFVEtarMENr TITLE, CHAPTER 9 1115 .J ANp TI lE RTANOAR09 Of SAN JOA WIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DI VIRIC N. <br />Joe ADDREBBroR APNF G!1 •t/[7 clrt S ?We <br />K r4J <br />PARCEL AIEE/APNI <br />OWTPER'B NAMEC!{!2 !S �N � [ SZI L 7 <br />ADORFFS S.� A%i L7 _ rL10M 1 J I �5 7 <br />CONTWICTOR. Ai6 CLSIn_ I k% p <br />Y AODDEgB�_��I ��D�! UC• .�I 1'110NE 1�$�'-p1! <br />Bum CONTRACTOR -$ 7TC'y �(•) 2%J" sE <br />ADDRESS__ <br />PHONES <br />TYPE Of WELL JMP• ❑ NEWWELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I <br />❑ OTHER <br />yy� /� �, ❑ INSTALLATION ❑ WELL SYSTEM AFPAIR ❑ CRORRCONNFCT REPAIR <br />Sv�»��, b ie ❑ N+'+ � n�. Np. � �� �j ❑ VAPOR EX7MC; ION wEEt E / <br />(TYPE or PUMPI/� �.� " 1 L — /— DEPTH n1Mr SEI ET. FRTer WATER LEJEL <br />c e g,- / I'PL S {�f/�-� Q out-or.REnVIcE WTI L <br />❑ OEOL}waN:AL WELL E ❑ OIL mONNa „ 1 <br />CI DESTRUCTION! <br />INTENDED URE <br />TYPE O WELL <br />❑OPEN mOTTOM <br />CANS TRVCj1pN RPECIFICADONS <br />AMOUNT REMITTED <br />Q <br />r.❑'T �IM�[NISTPIAL <br />EJ'DOMESTICR'"VATf <br />❑ GRAVEL <br />OIA. OF WELL F,XCAVATIOH <br />TAA• OF CONOUCTOR CASINO <br />❑ PUB(IOAIIUHICIPAI <br />PACKlSgE_ <br />TSE <br />❑ 1)"NEN <br />TYPE OF Cn <br />� <br />^-DI A. OF WELL CASINO <br />❑ IRg10ATq N(Aa <br />❑OTHER <br />ALTVC( <br />DEPTH OF GRat'II I EFAS <br />41ECNICATgN <br />❑ LIOMromHo <br />GROAT REAL INST All FD mY_T�T <br />GROUT BRAND NAME <br />APWIOx. <br />GROUT SFAL PUMPED' ❑ LI Yr Ne <br />L-I <br />CONCRETE PEDESTAL MY DRILLER: C]E] <br />Yw No <br />OO TII <br />LOCKMO CHESTER RO%ISTOVE 1W{ <br />PROPOREO COMRTRUCTIOMAMtUNG <br />METHOD: MUD ROTARY <br />AIR ROTARY AVRER <br />� CABLE OTHER <br />1 HE9EBY CERT IFY THAT I HAVE PREPARED TIAS APPLICATION AND THAT 7HF, WO rK WILL BF TRINE IN ACCORDANCE W11P1 PAN JOA <br />REGULATIONS <br />Of INE BAN JOAOIMN COUNTY, HOME OWNER OR LICFlVBFD AGENT'S PIf.NATUgE CERTIFIES r11E FOILOWMO; •1 CFRTIFVNTNATMjH THE RERFORMANCE OFLTIIE WORK FORWS ANI FWInC 1 <br />TMSPERMIT WIRBUFO,IM{ALLNOi EMILOY FEReroNm SUBJECT TO WORKMAN' FC GMFEN <br />SADON LAWSOF CALB'ORNIA_' cDMRAC7oR'6 HMSNO OR Bl1ECOMRACTINa 61oNATURE CErRIfIFe <br />TLLE FOLLOWING; • 1 C-UcAw THAT IN ALLTHE PERFORMANCE V THE FOR A FOR WTIR;H THIS FERMrr 19 ISSUED. 1 SHALL EMPLOY PERSONS BUmJFCT TO WORKiMAN'R CCMPENBA710H tAWS Dc <br />CALIFpRMA.' FII CANT MVRi CALL x4 IRouP11 U ADVANCE FOR AU. REOURED INH DONE T <br />C IIOBI 19.fAEE, CO TEKIWO. <br />/MI//L/ETE bRAWING AT LOWER AA HTDE <br />mlp,•gX �� .�rs-� E..E J <br />1. NAMES OF 8T PLOT PLAN ID— Ie 9,4,1 B-1. - 1,_ <br />RFETS OR ROADS NEAREST TO OR SOUND1Na THE AIC"FITY, I, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On rROr06EO <br />Z. OUTLINE OF TN PROPERTY, OFv m DIMENSIONS AND NORTH DIRECTION, <br />7. DIMENSIONED OUTLRIES AND LOCATION of ALL FXISTNLa AND FROFD efn EXPANSION OF *w*of. DISPOSAL SYSTEM!. <br />StRUCTUIIEB, lWtODINO COVERED AREAS, RUCH AA PAnn• ewnmwk m, LOCATION OF WFLLS WITHIN RADIUS OF ONE HUNDMiT HFTV FT <br />tlFPMTMENT WE ONLY <br />Ap•IIR•tl•n Acewl,A BY �,r(�r—�- i � '7v I <br />GreN Imp•,nm RY V pN, rLmP In.nxtlnn my_; /7'��V _' - — � � / '� <br />7" ONn (� fJC/J <br />OMtnrllen IMre-I'oE, <br />mI <br />ACCO UNTINQ UNLY: ARV rACS <br />-_ <br />PE CODES FEE LNFO <br />�S o <br />AMOUNT REMITTED <br />Q <br />PIE IlCARLI <br />�ooy8 <br />RECOVTD SY <br />DATE PEiiMITMETIYTCE REOUEAT MANSES <br />>� u o <br />INVOICE <br />0 j <br />Pub. Health Sere - Enviro 173 (3;'96) <br />