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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 /> ROTI-REFUIIOARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICBmpleRI IR TrlpRr:etel <br /> APPLICATION IB ITEM BY MADE TO THE SAN JOAUUN COUNTY FOR A PERAIT TO CONSTRUCT ANDPOR INSTALL THE WORK DESCRIBED.THIS APFUCATION IB MADE IN COMPLIANCE WRIT SAN <br /> JOAMIN COUNTY DEVELOWEEN�TLT�RTUUE.CHAPTER 8-1111 .3 SAM THE STANDARDS <br /> STTANDARDS OF BAN JOAMIN COUNTY PIBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ACURESSICIRR�Am, RIAXA�117-U\Y�1 tT^ IX1 t-tr R1�7A.F1.yN�ApU`'I\ CITY <br /> � T � n PARCEL SIZE/AMI <br /> OY A'S NAME IA?1P.NSZ.�YIl1 YlI1T1C"9 IIY1 We,5IT VYT\`/V I ADDRESS U'IYI';ym � eo&k � F+rorN fC�g,2�2YRr(o <br /> � , <br /> 1 y�'1L ` lg3+m Old l�(ateXvltlF,l�c1 /7 <br /> CONTRACTOR Fladiati C'YVYt 0Y/lC\ ADDRESS Ixf C RONEI Ilp- ' - nnn <br /> BIM CONTRACTOR Gr�l�-iwnT ADDRFe8g5o ij0Wc HVe.ITIUrhY%2.CA UCI 4n5 1 PHONE f 1-0- -c - l.Lw <br /> — <br /> TYPE OF WELLT IMP. XNEW WELL(5) ❑ BRRACEWNT WELL �MONOORM WELL l)L6§ ,L`L\�.��L�.\❑ OTHER <br /> ❑ INSTALLATION ❑ WELL BYBTEM REPAIR ❑ CR09842ONNECT REPAIR MUY`' ❑ VAPOR EXTRACTION WELL f J <br /> ❑N.El PS r H.P. DEPTH ROMP SET—FT- FIRST WATER LEVEL O <br /> IT PE OF FUMPI <br /> ❑ OUTOF-SERVICE WELL ❑ aEDR1Y61CAL WELL/ ❑ SOH HORN B <br /> ❑OERTRUCTION: <br /> INTENDED USE TYPEOFWELL CONSTRUCTION EPECIFICATI/O�NS 11 A <br /> 11INW6TRAL ❑OPEN BORON DIA.Of WELL EXCAVATION r�ypp,(5[�'l(,IUII^YL DIA.OF COMUCTOR CASINO 0 <br /> RR <br /> ❑ O0ME9TIC ' VATE X,ORAVEL PACIMNE TYPE Of CASINORTEEUP/C,>.fle'tl/ DIA.OF WELL CASINO 0 <br /> ❑ RMUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECUSCATON 9 <br /> ❑ IARIDATIONIAG ❑OTHER GROUT SEAL INSTALLED BY <br /> GROUT BRAND NAME E <br /> 0 MONITORING GROUT SEAL PIMPED:Oc�I YCONCRETE PEDEBTK 8Y DRILLER:❑Yw CIN. S <br /> AImROX.DE HL A(YLcLOCXRO CHESTER SOXMR <br /> TOVE PE S <br /> PROPOSED COMSTRUCTIOMIDAILUNO METHOD: MUD ROTARY AIR ROTARYAMER_CABLE OTHER <br /> I HF^ BY CERTIFY THAT t NAVE PREPARED THIS APPKJCATON AND THAT THE WORK WILL BE DONE M ACCORDANCE WTTH BAN"AMIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> IEGURATONS OF THE BAN"AMN COUNTY. HOME OWNER OR LICENSED AOENT'9 SIGNATURE CERTEER THE FOLLOWINO:'1 CERTIFY THAT N THE PEROREAME OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORIIMAN'S COMPfMSAMN LAWS OF CALIFORNIA.- CONTRACTOR-9 MRM OR WU ONTRACTNO SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS Ff . IS ISSUED.I SHALL EMPLOY PERSONS SUSJECT TO WORO.RAN'S COMP 6ADON LAWS OF <br /> CALIFORNIA.' THE/L/yPUCANT MU T CCA/�'A 24 MW IN ADVANOE FOR ALL IT GO M IM/SXMMMS AT 1 488- ". C/]O/M/JPNETEnpRAWllb AT LOWER AREA PROVIDED. !, <br /> 819 w X /� F t— �? L TRH. / I a L4Qr ✓ �p�AL "^- D.I. <br /> POT MAN ID,—t.%W.1 <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDIM THE PROPERTY. 4. LOCATION Of MUSE SEWAGE DISPOSAL BYBTEM OR rname D <br /> Z. OUTLINE OF THE PROPERTY.ONNq DIMFNSONS AM NORTH ORECT TH. EXPANSION OF 9EWAOE cosiro AL SYSTEMS. <br /> 1. DIMENSIONED OUTLINER AM LOCATION Of ALL EXISTNO AM FRDPOSM E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. <br /> STRIJCTLBES,NCLLMM COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAU(9. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY p <br /> nPvx..aen Ae..Pl.e er ^`�� D•u �� ,L•r ��� L-I/�� <br /> a,.IrwpeaBen Br 0.'. Pv^v Nrnosnen BY D.I. <br /> D,.v��n...(m.�n.etlen ev f I L D•t• <br /> ACCOUMTNO ONLY: AID, FACT <br /> PF CODES FEE INFO AMOUNT SEMVTTED CHEC ASN RECOVED BY DATE PRORTRFTIVICE REQUEST MUHNRT INVOICE <br /> .o rb ar ss <br /> Pub Health Sew.-Envlro. 173(1197) <br />