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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> S 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> rlv� (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmpMIB in TI(pDEUe) <br /> APJC AT CN 19 NEAE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOrOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE VATII SAN <br /> JOAOUIN COUNTY DEVELOPMENTT T <br /> RUE./CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY Mauc IIEALTN SERVICES,ENVIRONMENTAL HEALTH OMSIO7N.,(� <br /> JOB ADORESIVOR AM$ /J�// �( L1 l�Sl CRYz/�h/r[/u,/CLr�/_� PARCEL SUE/ArNI CIF II/ jC'C�`5,f <br /> OWNER'9 NAME Il l:` ��a�IMQ �ll (✓'Lr-L T ADDRESS ///7 ESC}!6/i EKIQNE♦ '� ->E <br /> CONTRACTOR / �.��I.RS hl � lln"LS Aoon[ee%J ,r �4,0v� kryd uce4;A6622? <br /> sun CONTRACTOR ADDRESS UCI PHONE I <br /> TYPE OF WELUPUMP: ❑ NEW WELL L L CEMENT WELL ❑ MONRONNO WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-0ONNECT REPAIR ❑ VAPOR EXTMCTION WELL I J <br /> ❑N.v:❑R.PMr N.P. DEPTH RUMP SET—FT. FIRST WATER LEVEL O <br /> D YPE OF PUMP, <br /> L ❑ OUT-OF SERVICE WELL)L,, (❑ GEOPHYSICAL WELL I / ❑ SOIL BONNO /h _'(� j�S <br /> ).DESTRUCTION: Old LL 1 I f E)�.t� l�'P/�W 1-'/ G -Y- CJ—Aa I(el,- �� ` � 1 (�J(('1N 14L <br /> op v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION BPFCIFICATIONS A <br /> ❑ INOVSTAIAL ❑OPEN SOrrom DIA.OF WELL EXCAVATION !/ DIA.OF CONDUCTOR CASINO O <br /> OOME9TICFTIVA7E , MVEI PACK/SIZE TYPE OF CASING/STEEL/rNC L, DIA OF WELL CASINO <br /> ❑ 1 OMMUNICIPAL -❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION S <br /> ❑ IFIRIOATIONIAO ❑OTHER GROUT SEAL INSTALLED GROUT BMND NAME ' E <br /> ❑ MONRONNO /'!? GROUT 6EAL fOMPED'UL ❑Ne CONCRETE PEDESTAL BY NUETL❑Yr N. 5 <br /> APPNOX,OM" //� �/ C LOCKING CHESTER BOXISTOVE PPE <br /> S <br /> PROPOSED CONSTRUCTIONIDINLUNO METHOD MUD NOTARY Alfl ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AHD THAT THE WOW WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S BIGNATUPE CEMIFIEB THE MULOWNU!"I CERTIFY THAT LATHE PERFORMANCE OF TIRE WOR(FOR WHICII <br /> I HIS PERMIT IS WSUM,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMFENSATSGN LAWS OF CALIFORNIA." COWMCTOR'B HIMMO OR BURLOMMCTINO SMNATURE CERTIFIES <br /> THE FOLLOWING: "I CEMIFY THAT N TINE PERFORMANCE OF TETE WOR(FOR WHICH THIS MMFR IS 1N9UED,1 SHALL EMMOY MPB NR SUBJECT TO WON, M'S COMPENBARON LAWS OF <br /> CMJFOWA,- THIN APPLICANT <br /> 1 MUST CALL <br /> �3A HNIB Ir <br /> OLIN ADVANCE FOR ALL REGURIM INSPI CONB AT 120EI/Md'LSI. COMPETE DRAWING AT LOWER AREA FIRKIDED. <br /> 1 <br /> BlP X l L E✓L�W�L�.�NJ Till. D 'P 1 I I.` v� D.RF�y[ <br /> ROT RAN RN.v.1.S WO S..1. 'I. <br /> 1. NAMES OF NTREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR DEPOSED <br /> 3. OUTLIVE OF THE PROPERTY,GI VIONO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE CNPONAL SYSTEMS. <br /> T. DIMENSIONED OUTLMFB AND LOCATION OF ALL EXIST0 AND PROMSM S. LOCATION OF WILLS WITHIN"MUG OF ONE HUMMO FIFTY P. <br /> STRUCTURES,NCLUDINO COVERED ASEAN SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE P Ici On AD"mm PROPERTY. <br /> 0 140 <br /> s J <br /> s <br /> 14 <br /> AYMENT <br /> r- <br /> SAN JOAUUIN COUNTY <br /> f _ PUBLIC HEALTH SERVICES II <br /> 317iP ERMYI'♦c{I1�J115N 1ANAf916�r <br /> DEPMTMENT U!E ONLY -7, <br /> I/ 9 <br /> hililk i—Aw.Fl.d BY �' D.1. \ 1. Ar.. <br /> arwn By D.1. <br /> DMi..¢ne((nyylrnP Ilen er �yL� ,DD..l. /2 'r{�47 <br /> C - !'�/� 9 - / S"-' • /-94 L7ESiYCLAErIaR) A2� !/ — NUIRo <br /> nccoDNrMNG oNLr: uD/ FAc• <br /> PF CODES FEE INFO AMOUNT REMITTED C ECRL BN RECEIVED NY DATE PEIMITI'MMCE REQUEST NUMBEIL INVOICE <br /> 3 <br /> vp 7 r <br /> Pub Health SON.-Enviro. 173(1/97) <br />