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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 95201-388 <br /> (209) 488-3420 <br /> NON-REFUNDABLE PERMR EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmpist6 ie TroputE) <br /> APRICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDPOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOMIENT TIRE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUHL/1`/WBLJC 'HE�A1LTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR AM' I 1 1� �yT 1 CffY ).YO LY�C 11 PARCEL SR&AMF <br /> OWNER'S NAME�`�„O KI Y L C' l /' fJ I T+ 4:50 ADDRESS �11''1ll / 1 PHONE J <br /> CONTRACTOR'I Ir/bl V (. LbI'P°/ILRI'rn.— ADDRESS N \V &)l 31'1 HONES I- 900 <br /> SUB cONTRAcroR4)j2e � ;2111�+'.�I 'h� AooREss lO .� uc.5Y�2J°8 MoNE 2n - 71Z <br /> �p �F���Te yy� <br /> TYPE OF WEL1l m, ® NEW WELL ❑ RERACEMEM WELL IC MONITORING WELL J III W-p ❑ OTHER <br /> ® INSTALLATION ❑ W SYSTEM REPAIR ❑ CROSSGONNE�C�T/�REPAIR TT�� ❑ VAPoR EXTRACTION WELL F ✓ <br /> {Jnr„ ❑Nsw❑PeP.ir H.P. K)k — DEPTH FVMP SETNTK FT. FIRST WATER LEVEL O <br /> R OF RIMED ❑ ❑ SOIL BORING S OUT-0FSERVICE WELL ❑ GEOPHV6ICAL WELL+ <br /> ❑DESTRUCTION' <br /> INTENDED USE TYPE OF WEL1 CO S"LCTON SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA OF CONDUCTOR CASING O O <br /> ❑ DOMESTICMRIVATE ❑GRAVEL PACK/SLII—. 1� TYPE OF CASIIWMTEELJPVC V� DIA.OF WELL CASING IL 1,.D <br /> ❑ RIBUCWUNICIPAL ❑ORIVEN DEPTH OF GROUT SEALIO IlI� 6PECIFICAMN Q Q'420 SII R �J <br /> ❑A RRIS <br /> IGATIONIAG ❑OTHER GROUT SEAL IN6TALLW BY 'Jp/ `K GROUT BRAVO NAME <br /> p, E <br /> MONITORING GROUT ERI <br /> AL MPEO: ❑Y— JRw CONCRETEPEDESTALBYORILLFR❑Y- ❑Ne S (� <br /> APPROx.DEITH LOCKING CHESTER SO)MTOVE RPE S �J <br /> MOP06ED CON&TRU,T,ONNW WNO MVNQD: MUD ROTARY NR ROTARY AUGER _CABLE OTHER <br /> HEREBY CERTIFY;THAT 1 HAVE PREPARED THIS AIMICATION AND THAT THE WORK WILL <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CBE DONE IN ,CORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> ERTIFIES THE FOLLOWING: PERFO <br /> ING:'I CERTIFY THAT IN THE RMANCE OF THE WORK <br /> LLFOR WHIG <br /> THIS PERMIT IS ISSUED.I SMALL NOT EMROY PERSONS SUBJER TO WORKMAN'i COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'S HIRING OR SUB{OMMCi1NG SIGNATURE CERTIFIES <br /> THE MULO NG: 1 CERf1FY THAT IN 14RFORMANCE OF THE WORK FOR WHICH THIS p R,,T I6 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIOAAN'6 COMPFN6ATION LAWS OF <br /> CALIFORN - HE ANT MMT C b Iq IN ADVANCE FOR ALL REQUIRED I ON6 AT I1O81 AEI6.OAT3. CO RETE DRAWING AT LOWER AREA�P—R'O VIDEO. q <br /> soma x nn.��/'n D Ill co <br /> D.R.f -(' �•T �� � !S <br /> ROT RAN TDF+''A Su l SwF V- u <br /> ♦, LOCATION OF HOUSE SEWAGE DSP06K SYSTEM OR PROPOSED <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR 6AND NOR THE REMONY. EXPANSION OF SEWAGE D6PO6M SYSTEMS. <br /> 3. OUTLINE OF THE RgPERTY',GIV1N0 DME-1 ALT, AND NORTH DI EROM N. S. LOCATION OFW WRATH MOUS OF ONE HUNDRED FIFTY FT. <br /> 3. DIMENSIONED OUTLINES AND LOCATKIN OF ALL EXISTING AND PIDPO6ED ON THE PROPERTY OR ADJOINING R10PERTV. <br /> 6IRUCTURES.INCLUDING COVERED AREAS SUCH A6 PATIOS.DRIVEWAYS.AND WALI(5. <br /> DEPARTMENT ME ONLY (%l <br /> Appllatbn A tg BY one ! Ar- <br /> Gre Impanbn BY OFN RmP ImpeCK M BY <br /> Dsb,cYon ImpFnron BY Dne <br /> 77 <br /> Cemmanp: /I <br /> ........ONLY: MDI FACE <br /> OE COD" FEE INFO AMOUNT REMITTED CHMC MASH RECENED PY DATE —.T.—..REOLIEST NUMBER INVOICE <br />