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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REfUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CamnistE M TrbfleEtq <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOON COUNTY FOR A PERMIT TO CONSTRUCT ANTIMIS INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY OEVELOPNLERT TIT!-E.C�AP�!/9{-]J8-1115.3 AND THE STANDARDS OF SAN JOAGUIN COUNTYPUBLIC HEALTH 9ERVICEB.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODRESSIOR APPHI �• PARCEL 91ZEIAR!! ) <br /> OWNER-8 NAME/ III ADDRESS �Y (KJ"UI ��N PHONE <br /> /'�,}�, /'F P { J,EA/17 <br /> CONTRACTOR adc FL<CA Ia- (5,s ^ �'�'��I � ADDRESS 1V> /`+GL/ I.Y L`; LICE `�+W�-✓1 g NEI le�/c <br /> SUN CONTRACTOR �G� r-"/ � AODREea:)0'1 ��� C' ��\.�/I LICE��PIwNE E7 7� �5r%( <br /> TYPE OF WELV : 11PUMPNFW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑N.❑R.a.N H.P. DEPTH PUMP SET-1,T- FIRST WATER LEVEL O <br /> (TYPE OF ROMPI ay/ <br /> ❑ OM-0E-SERVICE WELL ❑ OEOR1V61CAL WELL• IW ROS SOraNO B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �O A <br /> 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION !_ LI DIA.OF CONDUCTOR CASINO O <br /> ❑ OOMFSTICIMOVATE ❑GRAVEL PACK/SIZE TYPE OF CABIIHIISTEEL DIA.OF WELL CASINO O <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEH OEM"OF GROUT SEAL I L�e SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY t� GROUT BRAND NAME '-I� E <br /> CIMONITORINO GROUT SEAL PUMPED: ❑Y— [IN. CONCRETE PEDESTAL BY DRILLER:❑Y- [:JN. 5 <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE I 5 <br /> RIOPOSED CONSTRUCTIOMIDIRUMO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HERESY CERTIFY THAT I THAW PREPARED THIS APPUCATIUN AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AHD.1.AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> TMS PERmRT IS ISSUED.I SHALL NOT EMPLOY PERSONS"ACT TO WORKMAN'S COMPENSATION LAWS OF CALRORMA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIONATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMYF IS ISSUED,I SHALL EMR.OY PERSONS SURJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THIN <br /> �APPLICANT <br /> I MUST CA a fOW IN ADVANCE FOR ALL REQUIREDM/SSMT� M , <br /> KIMS AT I31 Am *S. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 91P.a X /j j(/Y114�AA./ /�� TRI ( <br /> . �l D.I. i6 <br /> RAT RAM IOr.w le Sa.bl S..I. 'I. <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYRTEM OR PROPOSED <br /> Z. OUTLINE OF THE PROPERTY,GIVING OHMEHSIONS AND FORTH DIRECTION. EXPANSION OF BEWARE DISPOSAL SYSTEMS. <br /> O. DIMENSIONED OUTLINES ANI)LOCAMN OF ALL EXISTNO ANO PR.OM"D S. LOCATION OF WELLS WRIHm RAC4U8 OF ONE HUNDRED FIFTY R. <br /> 9TRUCTVREB.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERLY/On ADJOINING PWIF Y. <br /> /L2 <br /> li <br /> DEPARTMENT USE ONLY <br /> Aeplh.tbn Aeesled BY DM. MY <br /> Geeul In.pMll.n B. D.I. P,,.,v NN.mnen Br DK. <br /> OMlrvelbn Irwp.clbn BY D.1. <br /> Cemm <br /> ACCOUNTING ONLY: I AID, FACS <br /> PF CODES FEE INFO AMOUNT REMITTED CHECKIMASH I RECOVEO NY DATE IEIEmTIEDIVICE REQUEST NLIMBRH INVOICE <br /> 2 . O l S 6 <br /> Pub Health Serv.-enVIro. 173(1 t97) <br />