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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) 458-3420 <br /> , <br /> " <br /> L t MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> {Comp14t1 IR 114 nEIuI <br /> AMICAFION IS ITEM SY MADE TO 111E SAN JOAOUIN COUNTY FOR A PERLIIF TO CONSTRUCT ANO/On INSIALI TUC WORK OESCRFBED.7409 APPLICATION IS MADE IN COMF'LIAFtcE WIN,BAN <br /> JOAOUFN COUNTY DEVELOPMENT Inttl.CHAPTER 9-1116.3 AND TNM STANDARDS OF SAN AOURNT <br /> I COUNTY PUBLIC IIEA 111 SERVICES.ENVIRONMENTAL IIEALiIVISION. <br /> JOB AOOREBWOR APHI (/(? f CITY <br /> I H D�` rA .EL BIZFJAPHO <br /> DLNRILR'i NAME 7 ADORE88 LONE4 <br /> CONTRACTOR7A ucal jl�TTIONE I <br /> 7i6� <br /> 8U8 CONTRACTQA ADDnE88 TICS PHONE I <br /> I <br /> TYPE OF WELUPUMp: ❑ NEW WELL © REFR110En1ENT WELL © MONITORING WELL f © OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTAACMU WELL 0 J <br /> I <br /> 11 N—�RepNr }I,p• DEPTH R'UMr BET421, FIRST WATER LEVEL <br /> flYi'EOFPVMPI <br /> ❑ OIIT-OFSERVICf WELL © OEO7IIYMCAL WTLL S ❑ BOIL 80NNO A r� <br /> 1 ❑DESTRUCTION: - -( (� <br /> .F INTtmED UEE 12E OF.WRLCONl7RUt LION iPFCIFICA IONS <br /> A <br /> ❑ INDUSTRIAL ❑OPEN BO T70M DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINQ O <br /> Wi DOMEBTICIE'IIVATE ❑OMVEL PAC1f1817E }YtV OF CABINOJS}itvM C DIA.OF WELL CASINO_ O <br /> ❑ PUSUCtMUNICIPAL ❑ONVEN DEPTH OF GFIOVT SEAL SPECIFICATION <br /> ❑ IRRIGAIIONIAG ❑OT}IER GROUT HAL INSTALLED BY GROUT BRAND NAME R ' <br /> E <br /> MOFK70RINq ` �—� I 0110UT SEAL PLTMI`EO: ❑Yr (IN. COHCFtE7E R'EDE STAL BY pnalTR:❑Y.a ❑Ne S <br /> APrnGX.OEPTII_ _ LOCKING CIIEBTER 80X1910VE 1'LFE <br /> 5` � <br /> i"RD PO4Eb COH9MUCTIONIMMLUNG ME71100: MUD FIOTARY MR ROTARY AUGER CATTLE OTHER <br /> e)UL'r CERTIFY THAT i HAVE P1IEPARED 71118 AFTEJCATION ANO THAT TILE WOFK WILL Be DONE M ACCORDANCE WITH SAN JGAOVIN COUNTY ORDINANCES,STATE LAWS.AND RULES ALIO <br /> REGULATIONS Of THE SAN JOAOUTH COUNTY. }IOME OWNER On L.ICENSEO AGENT'S SIGNATURE CERTIFIES T11E FOLLOWING;'I CERTIFY IITAT IN TINE PER rO1IlRANCE OF TIIE WOFIK FOn WIrICF1 <br /> NRS 1'EFSMN 18 188UEd.1 91IALL NOT EMPLOY PERSOHB SUBJECT 10 WORKMAN-1 COMPEFTMATION LAWS OF CAtFFOF36A.• COUIMCTOR'S tIUMNO On SUB CONIR/.CI TNG BIGNAtURE CERII►IE� <br /> (TIE FOLED <br /> WIFIG: 'I CEn1FFY TFIAT ST TII FIFdRM E OF TIIE WO FOR W,OC11 TTNB PEnmrr I9 ISSUED,1 St1ALL EMPLOY PER9ON8 SUBJECT TO WORKMAN'S COM FATION LAWS Of <br /> rAUFOI`" —4 PPIICAHT MUii C 3R}IO IT!ADVANCE FOR ALL AEOUIRED IMXPVCT10N/AT 12001 440,1431, COMPME ORA%MN(I AT LOWER AREA PROVIDED. <br /> 911n.d X L Till. <br /> nOT PLAN 0-v to 8ade1 Se.t. •to }� <br /> I. NAMES OF S1REE18 On MADS NEAREST TO OR BOUNDING 711E PnoPEntY. 4. tOCAI1ON OF HOUSE SEWAGE OMPOSAI SYSTEM On FYIQPOSED C/ <br /> !. <br /> 1 OUTLINE OF TIIE PnOPIr".GFVW40 OIMEN81ON8 AND NORTH DIFIECMH. EXPANSION OF SEWAQE DISPOSAL SYSTEMS. <br /> 7. DIMENSIOPtED OUTLINES AND LOCATION OF ALL EXISTMa AND I'ROPOSEd i. LOCATION OF WELLS WtT16UN <br /> N AAOIUS OF ILOnEO►IFFY F1. <br /> STRUCTURES,VICLUDINO COVERED AREAS 8UCII AS PATIOS,OFMVEWAY8.AND WALK8. ON THE PROPERTY On ADJOININO."lorERTY. <br /> f <br /> rF <br /> Nil <br /> CIA,V 04 <br /> �C <br /> o <br /> .. : DEG 1998 <br /> tAi <br /> P�e �. U NM0r FAL r11 St'iLN1C,F <br /> . - «•rte <br /> ENVIIIO <br /> 7J TAI IiEAl;lll L711'i51{IA <br />�tt 5y,' • 11``1 IPJ`DEPARTMENT URL:viftY it ll <br /> 6 ikipli. rlvn A—pled 8Y �l/'-���1 ` O.1• �•� •�tt� <br /> Vis, <br /> I±, 'r6y MnnK�ro.r Sr Oal. Aver Ineve.rlan 8 ' �� - bq �_ �-,�j•[J�J <br /> �vyu ° lruegnn I—P-11—BY Y <br /> } •.: ;1,. Oar. <br /> X. <br /> '*%ONLY. AID! <br /> FACT <br /> ,�' ,q,, i• .,� - - TEE INFO AMOUNT I11EM117to CHECK !CASH RECEIVED 1Y DATE P17MITIIERVICE REQUEST NUM1m INVOICE <br /> r-�.��....— <br /> i- 96 r <br /> DESS ll�Bf{ r a rd <br />