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APPLICATION FAR WELLIPUMP PERMIT �..-4 <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 4 <br /> P 0 SOX 380,446 N.SAN JOAUUIN ST.,STOCKTON,CA 26201.386 G(f(a - 7 14955 <br /> (204)400-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED CNVIIONMEM AL HEAUff <br /> ICampkil In Tliplical.l PERfvllT/SERVI(:ES <br /> APPLICATION 16 HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT 10 CONSTRUCT ANDOR INSTALL THE WOW DESCRIBED.THIS APPHCATION$6 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTERS-1 <br /> ►H[1APTER S-11115�.3�AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOa ALNX 95MRAPUF 3x12 ,1• CCkjf Ta'—, [� CfTY y� YiTel Yl PARCEL SRE/APNI �A� <br /> OWNR' <br /> ES NAMEPREAODKESS !TONE Iles:JT'1)-F� <br /> (-6 X- <br /> CONTRACTOR.,"OdSl k3rot r, �L^� ADORE6s s miT PgNE*409-3Z"3O0 <br /> BUB CONTRACTOR . AOORESS -, llCr PHONE I (•, <br /> TYPE OFwELLP"K ; ❑NEW WELL ❑mme"ENT WELL '❑M WFORING WELL I ❑OTHER '•�'�, Y <br /> y� <br /> 1 <br /> 13WSTAlLATbN ❑WELL SYSTEM NGPNR ClCRO11& REPAIR ❑NVECT REPAIR VAPOR EXTRACTION WELL I J 6] <br /> 13N—13 ROW H.P, DEPTH PUMP SET,--_FT. FIRST WATER LEVEL D <br /> I1YPE OF PUMP) <br /> 0 T-E OUWp__�/r-OFSERVICE WELL ❑GEOPHYSICAL WELL I !"�Sall BORING S <br /> ❑DEKUMTM: <br /> DEP OF TYPE OF WELL CONSTRUCTOR PECIFICATONS A <br /> ❑INDUSTRIAL 11 <br /> OPEN BOTTOM DIA.OF WELL EXCAVATION PX OLA.OF CONOUC7OH CASING p <br /> 1)LOMESTICMLVATE 0GRAVEL PACKISQE TYPE OF CASINWSTF[UpVC VIA.OF WELL CAWNO <br /> ❑PUBLICIMUNK:WAL ❑DIKVEN DEPTH OF GROUT MEAL SPECIMATON A <br /> ❑I RIGATIONIAQ ❑OTHER GROUT MEAL INSTALLED BY GROUT BRAND NAME <br /> ❑MG!liORINC GROUT BEN,EVMPED_❑Yw ❑Na CONCRETE FEDEBT/LL BY DRILLER:❑Yr 0,J S <br /> APPROX.DEITH.__ [7J TA1Er LOCKING CHESTER HOXMTOVE PIPE S. <br /> LZ <br /> PRGMSIED CONlTRUCTIONIOWLLINO METHOD; moo ROTARY AIR ROTARY AUGER._ Y CAOLE OTHE .(t <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WWU BF DONE IN ACCORDANCE WITIL SAN JOAGUIN COUNTY ORDINANCES,STATE LAWS,AND ROUS ANO v, <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY,HOME OWNER OR LICENI:EO AGENT'S SONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT W THE PERFORMANCE OF TILE YglSt FOR WHICH <br /> TSB PEFIWIT Ii ISSUED.L SMALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'a COMPpNMATOM LAWS OF CALIFORNIA..CONTRACTOR'S NSSNO OR SUBCONTM.CTINO MONATURE CERTIFIES <br /> THE FOLLDWYNO: -I CFRTNFY THAT IN THE PERFORMANCE OF THE WOOL FOR WHICUI THIS PEIMN IS ISSUED,1 WN t EMPLOY PERSONS SL cr To WOROAAX'B COMPE--FSAllum R OF <br /> CALIFORNIA-' T1NF ANT MINT C 24 HOURS IN ADVANCE I'M ALL REQUIRED INGIECTIONa AT I"ll Aii Jlt3.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> ag—i x TIIIA / VARA —G <br /> PLOT PLAN R".w Lo SaHAI SuIA No ' <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. {.LOCATION OF HOUSE SEWAGE DIa SAL SYSTEM OR PFROM"o <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIAENMNS AND NORTH DNIECTOH. EXPANSION OF SEWAGE DI6raaAL SYSTEMS. <br /> �.PIAENINONED OUTINEM ANO LOCATION OF ALLEXISTING Ally PROFOSED 6.LOCATION OF WELLS WITHIN RADIUS OF ONE mumu o.FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS MUCH AS PATIOS.DRIVEWAYS,ANO WALKS, ON THE PROPERTY OR ADJONING PFOPEHTY. <br /> wcr kpl6w, <br /> �.��_ OVM7MFNT <br /> USE QMIY <br /> AAF6Al1An Axplrl PT �/X///�f v�J`/f' `/� �`1 <br /> D.I. Vl A,r <br /> arms[IrrgcloA Rr D— Pwnn InAPACIIon Ky <br /> D.L. <br /> DrvrnU.A Nr.P.QeHO eY <br /> Owt. <br /> ACCO VNTNO ONLY: AOI FAC/ <br /> K coos fix lryc0 AMOUNT RDNIr TEb C A:ASM RECEIVED SY DAT INRMITnFJRIICE RCQUR+T NLM/DL IIIVOICE <br /> �� 7D/ <br />