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APPLICATION FOR WELL(PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ✓(/� � `�` � <br /> P 0 BOX 308,446 N.SAN JOAQUIN ST,STOCKTON,CA 9620 BB 06i 1,, <br /> 1209}468 420 �47 �. <br /> 11911-REFUNDABLF PERMITPM EXPIRES <br /> I YEAR <br /> FROR DATE ISRRED <br /> APPLICATION 16 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR rNSTALL THE WOR(DESCRIBED.THIS APPLICATfdlq'�AV*IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DLVEIDPAENT T /ClHAPTER B- 115.3(/A'{q�^THErSTAUDARDG of SAN JOAQUIN COUNTY PUBLIC HEALTH BUNICES,ENVXMINMENTAL RFRLIII DIVISION, <br /> JOB ADORER APN0 Par+ �_L� I `�I\1 IS <br /> 1(4-1 <br /> Tom\ Crry / / _ PARCEL&2E/APNF - <br /> `7{ <br /> OWNER'S NAME AODHEBR O/ W S � 7 7J l <br /> PHONE p <br /> CONTRACTOR_ LlCL_!/_� /� ADDRESS A1C, .3 . ..... �Gp� <br /> .1 SUBCONTRACTOR ADDRESS� I1CI �PHON ri EI <br /> i <br /> 11 TYPE OF W ry IPUMPI NEW WELL 1 3 REPLACEMENT WELL Q MONIToRNO WELL/ Q OTHER ? <br /> /CJ IFJSTAWIT[ON ❑WELL SYSTEM REPAIR Q CHOS&CONNECT REPAIR ❑VAPoRTJRRACTION WELL if � �! <br /> �G�1 N/aw❑R�alr N.P. OEPTN PIJMPSET FT, FIRST WATER 0 1_ <br /> ..]] O IMPI E <br /> ❑OUT-0FSERVICE WELL ❑GEOPHYSICAL WELL F 13 ROIL Down a <br /> ❑DESMCMN: <br /> INTFNOM UAE TYPE OF WELL CONFTRUG DN CPSCIRCATAONS A <br /> ❑ DUGTRAL QOPEN BOTTOM DIA.OF WELL EXCAVATICN FIA OF CONDUCTOR CASINO O <br /> OCE .11A. Q GRAVEL PACKISRE TYPE OF CADINGNITEELTVC <br /> II---II 41A.OF WELL CASINO D - <br /> -:� I.J PUBUCJMUNX:IPAL ❑DRIVEN - SPECIFICATION I <br /> T-I DEPTH OF GROUT SEAL A <br /> ❑IRRIGATIDWAG UOTHER GROUT SEAL INSTALLED SY �-I ORDUT BRAND NAME E <br /> 11MONIFORNO GROUT SEAL PUMPED:QY- ❑N. CONCHETEPEDESTALSy ORLLFFL❑y- ❑N. s <br /> ir <br /> APPROX.09" LOCKING CHESTER BOXABTOVE RPE -s <br /> PROIRT&ID EOM6TIIIIGTIDNJLIPLUNO ME71100:MVD ROTAS AIR ROTARY AUGER CARIE OTHER <br /> ffr <br /> 1 HEREBY CERTIFY THETA HAVE JOAQUIN <br /> C U THIS APPLICATION AND TRAT CENSED E WOR'WILL A URE C R ACCORDANCE WITH BAN JOAOUN COUNTY aFELIgANCEB,STATE TAWS,AND RO{B AND <br /> REGULATION 6 OF THE SAN JOEOUIN COUNTY.NOME OHOIFR OR UCENBFO AOENT':SIGNATURE CERTIFIER THE Ta110WINO:'1 CERTIFY THAT IN THE PERFORMANCE OF TRE WOR(FOR PXLICN <br /> THIS PERMIT ISISRUED,1 SHALL NOT EMPLOY FERSONB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. <br /> -_— THE FOLLOWING: 'I CFRIIFy THAT IN THE PERFORMANCE G 1 CONTRAGToR'G HIRING OR gUe-COWMACTMG SIONAIUFIE CERTIFlES <br /> -r_J F THE WOPH FOR WHICH THIS PERMIT IS ISSUED,1&HALL EMPLOY PERSONS SUBJECT TO WOROMAN'7 e co <br /> CALIFORNIA.- APPICANP JE1RT C IN ADVANCE FOR ALL IIFAUIRm IN AT 1308 468-741!, PROVIDED, N LAWS OF <br /> +/� 1 COMPLETE OPUIWING AT LOWER AHFl1 pgpylpFD.p <br /> ... BABrlyd X TId. <br /> POT FLAX[Or—I.B.,I.I Sw7. •I. L <br /> I,NAME:OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PIOPEM. 4.LOCATION OF HOUSE REWApE OISPOBAL SYSTEM OR PROPOSED <br /> I <br /> -..A! 2.OIffUNE OF THE PIgPE11TY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. - <br /> !-LXMENSIONED GUTUNE6 AND LOCATION OF ALL EXISTING AND PROPOSED <br /> S.LOCATION OF WELLS WITHIN PADKJB OF ONE HVNOPW FIFTY FT. <br /> STWIMFIEB.INCLUMM COVERED AREAS SUCH AS PATIOS.DRVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOR11Np IMIOPEHTy, <br /> Ln <br /> _ .o.. ..... .. .-_. .....y <br /> _•� _ .. _ _ <br /> f <br /> r` <br /> u� <br /> k=r <br /> L1 - <br /> .. � <br /> �� n . .� : <br /> ...c.... .,.......,. <br /> r,l.. �nd�L7. <br /> ,._ <br /> _otPMTMENT UFE ONLY <br /> - ApPMr.B.n A—pr.d By J <br /> GroM Jn pmcWm RY „e Arne IH�p46B.n BY Dal. n_.?r-� f•.' <br /> ..� bftt wde In tlbn BY <br /> GammNr Iii <br /> • �i <br /> ACCOUN71X0 ONLY; A.C. FAV <br /> PECODEA FEEINPO AMOURTFIGNS"E0 CHECKSA:Amm ITEC <br /> OVW BY DATE POWNTISRLyCE REOUPAT NUMBER INVOICE IL <br /> ■ <br />