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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JDA(lUIN COUNTY PUBLIC HEALTH SERVICES <br /> onIn ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 3BB, 445 N.SAN JOAQUIN ST.,STOCKTON,CA 96201-386 <br /> (209) 4683420 <br /> ` NOR REFUNDABLE PERMIT EXPIRES i YEAR FROM BATE ISSUED <br /> ICBmpinb in TEiplioebl <br /> /-PPUC/.TION IS HERE BV MAGE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOM DESCRIBED.THIS APPLICATION 15 MAGE IN CDMKIANCE WITH SAN <br /> IDADUIN COUNTY DEVELOPMENT/TITTLE.'{CPN M,Tm 9-1115.3 AF/TME 6TANDAPD$OF SAN JOAQUIN COU(NTY/PUBLIICC/HSEAAL/TLH SERVICES.ENVIRONMENTAL HEALTH D VISION. <br /> I�eO5 ADDIff55MA APF/ I `I 1. 'J ./'L''l - /JOU CITY ^' t t`Y9I I/J PAMEL wiu Pno / <br /> OWNER s NAME t"i flu tv AGGRESS /'{� �!(/� l� f�S I.4� i'J L PHONE I t'2 1,V <br /> LOTrRAcroR r ;: art .�� ADOREes =L �Y c. L f/!/!'/Y/- U.31 i l ANONE n yl/C-.. <br /> :UB CONTRACTOR ADDRESS LICO PHONE 0 <br /> ttPE OF WELVPJMP: ❑NEW WELL ❑ REKACEMFNT WELL ONTTO%NO WELLS ElOTHER <br /> ❑INSTMLATNIN ❑WELL SYSTEMA CROS6LONNECT REPAM- 1 ❑VAFORE%TM nONWELLI ✓ <br /> O New O Po HS. ��_ :-• RRST WATER LEVEL O <br /> TYPE OF.1 <br /> %B, ❑OUT-0FSMMCE WF1L� OEOPJITBICK WELL i ❑ SOIL BOXING B <br /> Cl DESTRUCTION: ! rT F r 1 e,ll1 �-I/,If, I,F,3 ER <br /> YTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> INDUSTRIAL ❑OKNBOTTOM CIAOFWELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ` <br /> yD OOMESTICIPRIVATE El GAA.PACN/SCE TYPE OF CASING/STEELNVC CIA.OF WELL CASINO O <br /> ❑FVBDLAIVNILIPAL ❑CwV DEPTH OF GROUT SEAL SPACIRCATION R <br /> 7 IRPGATIDN/AG ❑OTHPR GROUT MAL WSTMIED BY GXDUT BRAND NAME E <br /> 3 MDNITOPoNG GROUT SEN.ANNA D.❑, 0 CONCRETE PEDESTAL BV OPoIIER:❑Ya 13. S <br /> �X.DEPM LOCKING CHESTER SOXAMO VE PPE S <br /> PROMSES CON6TMICTAVERIWN3 MENpO: MUD ROTARY NR WT&W AUGEfl CABLE OTHER <br /> HE^EBY CERTIFY THAT I HAVE PREPARED THIS APKILATMN AND THAT THE WORK WALL SE CONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORWMIC <br /> NE6.STATE LAWS.AND InILE6 AND <br /> FGVIATMN6 OF THE SAN JDAONN COUNTY. HOME DINNER OR UCEN IED AGENT'S SIGNATURE CERTIFIES THE FDLLOWING:'I CERTIFY THAT IN THE PEARNMWAP <br /> ANLE OF THE [WR WHICH <br /> HIS PERMIT IS I65VE0,I ALL NOT EMROV PERSONS SUMCT TO WORKMAN'S COMPENSATION TAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR aUBCONTRACTING SIGNATURE CERHREB <br /> �HE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FDR WHICH THIS PERMIT IS ISSUED.I$HALL EMKOY PERSONS SUBJECT TO WOIONAWS COMPENSATION LAWS OF <br /> CAUFORMA.' THE AMUCANT MUST CALL 24 INIW6 IN ADVANCE FOR ALL REGUSAM INSPECTIONS AT MASS 46BY.25. COMPETE DRAWING AT LOWER AREA PROVIDED. \ <br /> �Bme X TIIIe <br /> PLOT NG THE MOPE le SeNel Smb <br /> 2 NAMES OF STHEEPA OR MAN NEAREST TO OR BOUNDING THE REC ION. <. LOCATION OF HOUSE SEWAGE OI SYMM VSTFM OR PROPOSED <br /> ^-. OLRUNEOFTHETLJNFS N LOCA IONO OF <br /> AND NORTH OIPROPOSE EXPANSION OF SEWAGE DISPOSALSYSTEMS. <br /> J.W VCTU NSD INCLUDING <br /> AND LOCATION OF ALL E%ISRNI AND P10Po6m S.LOCATION OFRTY O WITHIN RADIUS PE ONE XVNDRED FIFTY FT. <br /> STRVCNRES.INCLVOING COVEMO AREAS SUCH A6 PATIOS.pNVEWAV6.ANO W.S. ONTM PROPERTY OR ADJOINING PROPERTY. { <br /> T� <br /> 11 f` ' k yi[. I <br /> IL <br /> PAYMENT RECEIVEn <br /> ; <br /> MSR <br /> Ad JOA <br /> LMFIIP IT FI�U!rli tk1 I14 . <br /> 'i f'J'.4RGPtvikiVlAtNAlll fIIVI i�lm %_.I -- j <br /> ` DEPARTMENT UAE ONLY <br /> bpll`+rbn An FNA,BY ZI Arm=Ljf_ <br /> .reu Irvpclun BY DoN —A Impsibn BYE De1s�+Pr///V <br /> =n rrnim ImpeeAbn By DwN TT� <br /> Comm <br /> O ONLY' NOI FAC! <br /> y PE COOEi FEEIHFO MNOUMTR TTFD MEC /CA6N RECEVPD BY GATE AEAART/SERVUCE REQUEST XUIMBEA INVOICE <br /> ��� <br /> I 3 55 <br />