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APPLICATION FOR WELLrPyJ")%PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC� "H SERVIGES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 32%300.EAST WEBER AVENUE,STOCKTON,CA 95201.488 'SCANNED <br /> (2091 469.3420 <br /> NON-REFUNDABLE HAW EXPIRES I YEAR FROM DATE ISSUED <br /> ICamplala In Trlptkatal <br /> APPI IcAYIoN IS HERE BY MADE TO THE BAN JOAOUIN COUNTY TOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 1$MAW IN CoMPUANCE WRH SAN <br /> JOAOUIN COUNTY DEVELOPMENt TMJP-CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUINIRON <br /> COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOS ADDRESSOR APtN y I / d CITY t. co I2 12 _- PARCEL SCVAPNN y� <br /> OVV NER'B NAMr._� /� Pl E Ll AJ q nDORESa��.l?•pp, ��f4L.i I,,;JV-5 PHONE P9C,L/ QYZ- <br /> COIYTRACTORL{J ) ~ L ADDRESS Yd.-bo 9' 5F3 r {I,E LIGat� PHONE I X45-7' - _. <br /> rY55,ti 3� <br /> SUS CONTRACTOR ADDMISS LICA PHONE/ <br /> TYPE GFWELLIPUMT NEW WELL C]REPLACEMENT WELL ❑MONRDRING WELLI ❑OTHER 4 <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION VMELL <br /> C"h ❑ . <br /> E <br /> Naw❑Aaelr H.P � DEPTH PUMP SET�FT. <br /> FIRST WATER LEVEL <br /> HYPE Of PUMP) <br /> ❑DUt-*F-6ERVICE WELL ❑GEOPHYSICAL WELL f ❑ BOIL SORING - <br /> ❑DESTRUCTION: <br /> INyTENOSD 6E TYPE OF WELL CONETAUCTtoN 6FECD7CATIoNS S A <br /> LJ INDUSTRIAL O�P�EN BOTTOM VIA.OP WELL EXCAVATION j`P' DIA.OFCONDUCTORCASWG!f)QVif ^� <br /> ❑DGMESTI IMVATEOLf RAVEL PACKMZF TYPE OF CASIHOISTEEIJPVCY DEA.OF WELL CASINO JCI <br /> ❑PUBLIGRI <br /> MUNICIPAL ❑DRIVEN DEPTH of GROUT SEAL I�YJ SPECIFICATION IO <br /> IRRIGATIDNIAG ❑OTHER GROUT SEAL INSTALLED BY/w2,2,,h c I.&&-�l I/B./Tli,I cNORDUT BRAND NAME^,S��7^54XI4 <br /> LE MONRORING I GROUT SEAL PUMPEPT[a Yr ❑Na CCNCRETE PEDESTAL BY DRILLER: IV- ON. <br /> APPROX.DL'PTN LOCKING CHESTER BOXISTOVE RPE S <br /> PROPOSED CONaTRUCTIONMAILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE X OTHER <br /> 114MBY CERTIFY THAT I HAVE PREPARED THIS APPUCATON AND THAT THE WORK NRLL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAGUIN COUNTY.HOME OWNER OR Ltct"ED AGENT'B SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH <br /> T1416 PERMIT tS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP4H6ARON LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -t CERTIFY THAT IN THE PERFORMANCE OF THE WOrK FOR WHX:II THIS PERMR W ISSVED.I SHALL EMPLOY PERSONS SUBJECT TO WORMAN'S COMPENSATION LAMINS OF <br /> CAUrO1QaA.' E /`�T MIJITT CIA/LL.2,Iq IN AIWANCE FOR ALL REOURED INSPECTIONS AT E20aH 4"4422.COMPETE DRAWING AT LOWER ASIALPROVIDED. "'"7 <br /> q*­d X K TA/ -- -—TIIa A.Ia J/� / <br /> PLOT PLAN IDraw m S—W Smola 'm <br /> I,NAMES OF STREETS OR RDADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSIOH OF BEWADE DISPOSAL SYSTEMS. <br /> 3. bIMENSIONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUMORED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .. .. ..,h ..... ...i ... <br /> v <br /> &�..+ <br /> q. <br /> t <br /> .;.. <br /> .,. i.... .....,:, <br /> . .. . .. __. .. .,, ,.. <br /> : <br /> DEPARTMENT WE ONLY <br /> l'J <br /> APDIIeWim AeWted BYy//� 0— Ma. <br /> Grolx ln,Psrtlan BYE ✓ / Dsta 'T ( Pump NuPecden BY Oata� f <br /> Pw[r.�clkn lrreaorien BT 14 <br /> D.I. <br /> Cemmenl.: <br /> ACCOUNTING ONLY: AR7V FAC# <br /> m. ..xm <br /> FE CODES FEE INFO AMCHECK!OUNTRDWTTEP BH RECOVER BY OAT. PMCTaPAVICE REODUT NUMBER INVOICE <br /> O is9 d ;2- '/Zi- <br /> 3?oar <br /> r <br />