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it <br />0 WIW I( <br />l• - <br />of,-, (le d <br />A2 &1& <br />M 5 <br />tr2111e4 ,--;AL “ <br />'1131 4.1( <br />Dole ApplInotIon AcooOlt.4 <br />Ofoit1 InoonetIon fly <br />tinitttoction tri.nontInn fly <br />Cornr000lo, ,. <br />Area 0 <br />0.1. /a <br />Plontt InopectIon Ely <br />.4•11,' <br />`PPLICATION FOR WELL/PUMP PERM!" <br />SAN— JAQUIN COUNTY PUBLIC HEALTH SER ‘.2.ES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />!Complete In Triplicate) <br />APPLICATION ft; nrnr Sy MADE TO TIIE SAN A/AMIN COUNTY ron A PERMIT TO CONSTRUE:7 AND/011 INSTALL ENE WORK orscrunro. THIS APPLICATION IS MAItt IN COMULIANCE V1/111/ SAN <br />srncrs. ENVIRONMENTAL HEALTH DIVISION. .1 15/ <br />IlL <br />lot <br />- - . <br />TYPE OF WELL/PUMP. D NEW WELL El REPLACEMENT WEI.L <br /> <br />• MONIT0runin wro LI <br />INSTALLATION 0 WELL SYSTEM nrrtin <br /> 0 NOW El liOrl ell <br />litrc or mum <br />CI son nonsin <br />Cri33-7 <br />cows/kr:Ton <br />sun CONTRACTOR <br />ion snonrssion Art411 <br />JOAOUIN COUNTY 7 DEVEIOPMENT LE, CHAPTER 9-1)1 5.3 AND THE STANT/ARDS Or RAN JOA01/1N COUNTY PUFII.IC HEALTH ‘s <br />oVVNEn.s NAME -12e4)/34 sonnrse •at•''C- <br />frr#iiiL, <br />H.P. <br />El otitor-srmscr WELL <br />612e,d,non, Aeggw, ri=2-uir <br />cnoss CONNECT nrrsun <br />DEPTH mom, SET rt. <br />OIE0NIYCICAIWFTLI <br />OTTIF1 1 <br />APOI1 EXTRACTION WELL I <br />mint WATER LEVEL <br />PARCEL SIMATILP <br />13i ./',_.7i'"i. <br />rim 9:47( <br />orsinucTioN! <br />INTENDED bSE <br />Eli ninusinsti <br />CI DOMESTICNIIIVATF <br />Li IC/MUNICIPAL <br />IRRIGATION/A0 <br />El moNtionnqn <br />Ammo X. DEPTH <br />TYPE OF WELL <br />°Pm nortort <br />(TRAVEL PACK/017E <br />nnwrN <br />El oinrn <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WEIL EXCAVATION <br />TYPE or cssworstrn . <br />DEPTII OF (mom SEAL <br />nnour SEAT INA1 MT MI SY <br />GROUT REAL rurirro. VI. ON.. <br />nuk. or connuc TO/1 CASING <br />01A. Of yvnt cm:ma 2. ti g/‘ <br />SPECIFICATION <br />(mom SRAM NAME <br />CONCRETE PEDESTAL IVY INTILLErt: El Yoe ON., <br />LOCKING CHESTER ROX/RTOVE rtry <br /> fon ROTARY sunrn (num <br />FE-67— -7t-/TA-C- <br />enoroncn CONIIITTIUCTIONMETILUNG METHOD: MUD nottny <br />nrnrny crnnry THAT 1 NAVE rnrriknro THIS APPLICATION ANt) 111AT /NE WORK WM. RE DONE III ACCORDANCE WITII PAN iosousi COUNTY ORDINANCES, STATE LAWS, AND ntnrft AND <br />PERIN ATIoNA or TIIE SAN JOAOINEI COUNTY. 110ME OWNER on LICENSEE) AGENT'S rsoinkrunr crmirits T/IE FOLLOWING: 1 crrinry THAT IN THE nrntonrtsucc OF 111E yyont FOR wmcn <br />TIIIR rrnmir IS ISETUE.O, I cowl NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS or csurontss.• CONTRACTOR'S HIRING OR SUITCONTRACTINO SIGNATURE cryttsirs <br />TI1F rot towwn: • I CERTIFY MAT IN TUE nrnrontimicr Or TIM wont ron WIIICII 111111 PERMIT IS Isom. I SHALL EMPLOY Pensorie ITLISJECT TO WORKMAN'S COMPENSATION LAWN or <br />cAl IronNIA.- • PplIcANT MUST CALL 24 nouns IN ADVANCE FOPI ALL ITEGISTIE0 INSPECTIONS AT 120111 41111-1431, COMPLETE DRAWING AT 1.0WER AREA nnoyforo. <br />flloond X <br />PLOT PLAN Ow. to Rowel (Toole <br />I. NAMES or STREETS on noAns NEARF.ST TO on POUNDING WE rnorrnry. <br />7. OUTLINE OF THE PROPERTY. GIVING DIMENSIONS AND NORTH <br />1. OIMENSIONED 01111./NES AND LOCATION or ALL EXISTING AND PROPOSEO <br />nucTunEs, INCLUDING covEnEn AREAS SUCH Al PATIOS, DRIVEWAYS, AND WALKS. <br />' to <br />4. LOCATION or 110USF SEWAGE 11111POSAL ISYIDEPA on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITITIN mina's OF ONE nunrsiro nrry FT. <br />ON THE PROPERTY on ADJOINING Pnortnty, <br />dloO <br />f <br />... <br />......... <br /> PAYMENT ..... <br />rtEcF),IfFr <br />JUL 7 1998 <br />ENVIRONMENTAL HE,Aijlç DIVISI; II <br />purluc HEAL ill SETIVIC,ES <br />SAN JUA(,)(JIN COLIN Ii <br /> <br />...... • . <br />_ <br />nernnTmeter USE ONLY <br />I ACCOUNTING ONLY: f AIDE r ,Ac, <br />PE CODES FEE INFO AMOUNT REMITTED RECEIVED ITY DATE PERMIT/SERVICE REQUEST NUIVINER INVOICE klIECK/OCASII <br />40, 0 vv. _uatE_____ 717 cv 6 / 7 (,, <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />.41 <br />tq <br />I. /13 71,4 *.r