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{ r) <br /> + r <br /> 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 /> �0/-� (209) 468-3420 NO*-REFUMUA9LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompkid In TI�II0s18I <br /> APILICAIION IS HERE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PEFWIIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,7111*APPLICATION IB MADE IN COMPLIANCE WIRil SAN <br /> JOAQUIN COUNTY DEVELOPMENT IFTLE.CHAPTER 8.1115.3 AND THE STANDARDS OF SAN - AOUIN COUNTV PUBLK:NEA TH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDREBSIOn APNM ` C/ Clri =40NIE <br /> APNI <br /> OWNEWS NAME ADDRERB <br /> I yJ�� <br /> CONI RACTOR� .(�T C�.Sa•..�CZ,,. -L',.C� AbDREBB 'r` LIC jy IONE/ ` C <br /> RUB CONTRACTOR ADDRESS LRCM PIIQNE I <br /> FT'PF OF WELL/ JMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MON{TORINU WELL R ❑ OiHER <br /> (/f ❑ ,INSTALLATION ❑ WELL SYSTEM AEPAIn ❑ CRORB-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL ItJ <br /> FF-�L11.lY"„_ ❑H. Rap 1. Il.p.�` DEPTH PLIMP SET FIRST WATER LEVEL ��� •`� <br /> ry (TYPE OF PUMPI O <br /> II rte. <br /> '� © OV7.OF-SERVICE WELL ❑ QEOI'IIYWCAL WELL M ❑ ROIL RONNU S �� <br /> * ❑DESTRUCTION: -- <br /> INTENDED UiE TYPE OF WELL CON><IR_UCTION SPECIFICATION* A <br /> LI © INDUSTRIAL ©OPEN BOTTOM DIA,OF WELL EXCAVATION VIA.OF CONDUCTOR CASINO D <br /> K-MIESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINO/STEELlPVC DIA.OF WELL CASINO D <br /> ❑7T FUBLICIMUNICRPAL DRIVEN DEPT II OF GROUT SEAL SPECIFICATION <br /> �.FIRIIOATIOWAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME R <br /> ry <br /> ;,.J MOMIGRING r GROUT SEAL PUMPED: ❑Y— E❑Na CONCRETE PEDESTAL BY DRILLER:❑Y- ❑Ne S� <br /> APPROX.DEFT" LOCKING CHESTER BOX/STOVE PIPE <br /> i^?flOPOGED CONSTRUCTIONIMLLINO METHOD: MUD ROTARY <br /> Ain ROTARY AUOIq CABLE DS <br /> f T11ER <br /> 4EBY CERTIFY THAT I HAVE PREP \�'—�• <br /> ti.!FIEARED THIS APPTIO <br /> LICAN AND THAT 711E WORK WILL BE DONE IN ACCOnOAHCE WITH BAN JOAGUIN COUNTY ORDINANCE*.STATE LAWS.AND AULES AND,x-p <br /> REGULATIONS OF THE SAN JOAO"COUNTY, HOME OWNER On LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERPORMAIICE OF TILE WORK FOR WHICH 1^.11 <br /> TISK PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSON$SUBJECT TO WORKMAN'/COMPENSATION LAW*OF CALIFORIIIA.' CONTRACTOR'S HIRING OR SU"ONTRACTINO SIGNATURE CERTtF1E4 J <br /> �INE FOLLOWING: '1 CERTIFY THAT IN TIL RFORMI E OF THE WOnK FOR WHICH THIS PERMIT if ISSUED,1 SHALL EMPLOY PERSONS*ABJECT TO WOILKMAN'S COM SATION LAWS OF // <br /> :ALIFORFAA' PPUCANT MUST C 2�HO IN ADVANCE FOR ALL REOL"ID INSPMTION$AT(2061 4".3427. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> rJ C A <br /> Btpr+ed X G Till. CJ' .. „-.. D.I• <br /> T— <br /> ' PLOT FLAN{D.enr to BaMeI 8a.1. 'le . <br /> i. NAMES OF STREETS On n0AOS NEAREST TO On SOUNDING THE PflOPERTY, 4- LOCATION OF HOUSE SEWAGE DISPOSAL$YST{I.T OR pnDrOGEO �y <br /> :. OUTLINE OF THE PFIOPEFTTY,OIVIMO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE 1>1BPGBAL SYSTEM*. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXINTWO AND FROF'OBEO S. LOCATION OF WELLS WITHIN FUUMU$OF ONE HUNDRED FIFTY TT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS:PATIOS,DRIVEWAYS,AND WALK*. OH TIRE F'ITDPEnTy On ADJOINIFN3 Pnofq TY. <br /> 771 <br /> i <br /> 4 %� de <br /> Fri) <br /> PEP,: 3 1998 <br /> SA;4 <br /> �� CHFrk II`Er(VlF,i:b t <br /> Y nlvn lJ`n�r 1[r 1nl jI a(-'FJ 1 iSlc,l <br /> DEPARTMENT USE ONLY <br /> AppRoollun A—opted 8Y Arw <br /> 41� <br /> tlb <br /> O-%A knpfttl—BY O•b P—p k 013-0-n By <br /> D...t,l+clltlry I—Pe tk—By <br /> �Comn+n+l•:. <br /> k <br /> . ACCOUNTING ONLY: AIbM FACT <br /> P£CODE* FEE INTO AMOUNT REMITTED CHECK X:A/H RECEIVED BY DATE 1`131MITISERVICE REQUEST NUM*ER INVOICE <br /> �0 7`�b ' S�1 c_ I f.1575 U6 1 E� <br /> e <br /> i J-111, 1-- Fll"ifn 17n '1 In-1 . <br />