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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX aft 304 EAST WEBER AVENUE, STOCKTON, CA 9MUMB <br /> 12OS) 460.3420 <br /> NUN EFUNOABL PERMIT EXPIRES I YEARNI DATE 123140 <br /> IC "left In Trfplmt* <br /> APPLCATION IS HERE BY MADE TO THE BAN JOAQUINI COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE N CCArIPUANCE WITH SAN <br /> JOAGUIN COIJARY DEVELOPMENT TTTIE,CHAPTER 8-1115.3 AND,THE STAR S OF BAN JOAGUNN COUNTY PUBLIC <br /> .HHEL//,�TH�SE_4VICEB,ENVIRONMENTAL HEALTH IXVISION. <br /> JOB ADDRID&MR.MW CITY PARCEL SMApN/ <br /> OWNER'S NAME G AIDOIES L, 1 �P E //�tt�I <br /> CONTRACTOR a~ ` ADDRESS LIC# PHONE 125►�I <br /> wr <br /> ws CONTRACTOR AOpPIESi LRCs PHONE S <br /> TYPE OF Wa 1mmp, jv(q@EW WELL ❑ REPLACEMENT WELL ❑ moHITOIMNG WELL/ ❑ OTHER <br /> ❑ NSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRDBbCONNECT REPAIR ❑ VAPOR EKrAACTION WELL <br /> Rl"P'E OF FUMPI O m.❑R.,,* H.P. DEPTH PUMP BET FT. FIRST WATFA LEVEL <br /> ❑ OUT-OFSERVNCE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL WRING ■ <br /> NIFT11000 Utu— TYPE OF WELL GO—MIMLICTIONA <br /> ❑ mmnrrRAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ` CAA.OF CONDUCTORCAMINO <br /> DOMESTICRISVATE OWM PACK1SIiE_ TYPE OF CAiPOWEEUPVC DIA.Of WELL CASING D <br /> ❑ PIISLIC^#JM'CWAL ❑DRIVER/ DEPTH OF GROUT BEAL _ SPECIFICATION <br /> ❑ ISIGATION►AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME B <br /> ❑ MONTRDRINO ' / f WlOUT TEAL PUMPEO:Tir ❑N. CONCRETE PEDESTAL BY LFR:❑Y. S <br /> APPROX.D@TN LOCKING CHESTER DOXASTOVE FRPE____ <br /> RUOPOSNO CONSTRilCTIDNIt6"LlRNG METHOD: MUD ROTARY AIR ROTARY AVGER� CABLE OTHUL— <br /> I NEFEBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDAWO WITH SARI JOAGUN COUNTY ORDINANCES.STATE LAWS.AND RILES ANq <br /> RE LATIONS OF THE SAN JOAOUN COUNTY. HOME OWNER OR LICEI,iSED AOENT'"SIGNATURE CERTIFIES THE TOLLOWING:'I CERTIFY THAT NI THE PERFORMANCE MANCE OF THE WORK FOR WHICH <br /> THIS FUN"IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOf'lKMAN'"COMPENSATION LAWS OF CAP„IFORHIA.' CONTRACTOR'S WRING OR SIIB COHTRACTNIB IIGNATURE CERTIFES <br /> THE POLLOWM: 'I CERTIFY THAT N THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO MORICMAN'S COLVI/"ATUON LAWS OF <br /> CALIFORNIA." THE APPLICANT MUST CALL 114 HOURS IN ADVANCE POR ALL.REOUR®NrSNIOTIONS AT Ii0AI 4AW44M COMPLETE DRAWING AT LOWER AREA PROVIDED.Sllnad X f" ! <br /> Tlfla A <br /> PLOT PLAN Draw to Saahi SeaN 'ts <br /> I, NAMES OF STREETS OR ROADS NEAREST TO OR SOON DING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> t. OUTLINE OF THE gUOFEDTrY,ORMq DIMENSIONS AND NORTH DI ECTION. EXPANSION OF SEWAGE DNNFO"AL SYSTEM <br /> S, DIMENSIONED OUTLRNB AND LOCATION OF ALL EXISTING AND PROPOSED ■. LOCATION OF WELL"WITHIN PAWN OF ON HUPIDRED FIFTY FT. <br /> STRUCTURES,INCLVDM COVEPED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJODNNG PROPERTY. <br /> .. _ .. _ <br /> lel� 4 <br /> !l= '�<. ... <br /> W. <br /> EL' Iry R Ie <br /> RL1�B IC'FiEA�TI-i , <br /> .. i= } D . Ek�T�AL�€EALTkI.T}!1�1.�.. <br /> -? mb...�:. .. <br /> DEPARTMEIIT US1 ONLY ' <br /> Appke sn Amm"ed By. <br /> Drrhts Arr <br /> OrmA Inapaatlan By_ ZLl oats P—W IrwNm Ian By oats <br /> DrInMtl°n kWPWdWA By. Dab <br /> EUNTING ONLT: AXI FACF <br /> Bill <br /> ODEl Fii IfSiO AMOUNRT RRY"TTEDC JCASH RECEIVED SY DATE PINUNNTJSR6IVIC"RBGUEDT wAigiEI INVOICE <br />