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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 /> ZION-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmp1E1$ In TrIpRF$tEl <br /> APPLICATION 19 PIER BY MAGE TO THE BAN JOAOVIN COUNTY FOR A PEWIT TO CONSTRUCT ANDAIR INSTALL THE WORE(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WAIT BAN <br /> JOAQUIN COUNTY DEVEL/OOME�NTL,T'ALE,1,CHAPTELR 9-11115�.3 AND THE STANDARDS OF SAN JOAOOIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRES&ORR�APN/ I\IRY,('�I�Ih�i }��'IN- CYT {�� O\L-.I 33ri CITY IYL� PARCEL MZFJAPN1 <br /> OWNER'S NAME L,(?wbl, D6inl)Awi Pw1rai ik* (DDRW I AODRE Be �L'1V1SY7'UfiL� �IJWJ� PHONE <br /> CONTRACTOR Rcldiaa'1 �hteX i.�ly�/1 '� AOD11[BS= Okll�llz[i:lv�ll(,nd <br /> - VCs PHONE/V I <br /> BVB CONTRACTOR�1�Qli[l L/(IIII A ADONESS qti&NQIA lqQ�''Ma f 111Cz 0 VCs T PHONE/SIL ' I, (NV <br /> M <br /> TYPE OF WELLIMP: NEW MI-45) Ti <br /> ❑ REACEMENR <br /> T WELL ofMONTTONO WELL I, „w \❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAFOR EXTRACTION WELL/ J <br /> 11 N. R.PN, N.POEM"PUMP MET FT. FIRST WATER LEVEL p <br /> AYFE OF FHMPI <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ BOIL BOWNG B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS u./ 11`1� LI A <br /> ❑ INDUSTRIAL ❑OFENBOTTOM DIA.OF WELL EXCAVATION `ry,L,2 Iy, II��J/I((-,z DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTIOIF11VATE AOMVEL PACK/SIZE TYPE OF CASINOIBTEE 40 I1YV DIA.OF WELL CASINO O <br /> ❑ WBLWIMUNICIPAL ❑MwN DEPTH OF GROUT SEAL SI4CIFIOATION R <br /> ❑ IROBOATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME E <br /> 0MOMTORINO/C1 � �y� 1' 111 GROUT SEAL PUMPED:K Yr ❑N. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑N. 5 <br /> APRIOX.DMH \1 �1yAI I\E�� LOCKING CHEMFER BOX/STOVE APE S <br /> PROPOSED CONSTIIIICTIONIDRWMO METHOD: MVD ROTARY AIR ROTARY AMER x CABLE OTHER <br /> I HEBEBV CERTIFY THAT I HAVE PREPARED THIS APPLICATION AM THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE MAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE FEMOBMANCE OF THE WORK FOR WMICII <br /> THIS PERMIT 19 ISSUED.1914AU NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR-8 HONG OR SU"ONTRACTNO SIGNATURE CERTIFIES <br /> THE FOLLOWINO: -1 CERTIFY THAT N THE PERFORMANCE OF THE WORC FOR WHICH THIS PEPMT I8 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOIIRMAN's COMPENSATION LAWS OF <br /> C8 FORMA.' THE ASRIC T C i ]/WEIRS IN ADVANCE FOR ALL REQUIRED INBPFCTIONB AT 1�/°/1 AtlJ122. COMF ETE DRAWING AT LOWER AREA MOVIDED, q� <br /> /L�/J 4'"` Till. 4, lr/L,^G;— 44'1.vA.�CiI <br /> D.I. <br /> BLOT"N ID,.I.B W.l Ba.l. 'ro <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE 9EWAOE DISPOSAL SYSTEM OR PROIOBED <br /> E. OUTLINE OF THE PROPERTY,OIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISFU9AL SYSTEMS. <br /> 3. OIMENBIONEO OUTVNFS AND LOCATION OF ALL EXISTM ANO FISOMICED E. LOCATION OF WELLS WAMN NACIUS OF ONE HUNDRED FIFTY R. <br /> STRUCTURES,INCLUDING COVERED ARU$MUCH AS PATIOS,DRVEWAYS,AM WACBS. ON THE DROKITTY OR AOJOIMN()PROPERTY. <br /> 011)53A <br /> >t1' Lt's 15�F j :_ <br /> UV) 151. <br /> LTYI 15E6 I <br /> tin IbU <br /> LM 108. <br />