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'PLICATION FOR WELL/PUMP PERMIT <br /> SAN,..wAOUIN COUNTY PUBLIC HEALTH SEI ,FS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> �� (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TrlpReelel <br /> APRICATION 19 HERE BY MADE TO THE BAN JOAQUIN COUNTY FDA A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORID-CRIBFO.TIIIB APPLICATION 19 MADE IN COMPLIANCE WHIZ SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-y1115.3 AND THE "OAF 8 B JOAQUIN COUN/TY RIBLIC Ham)LTA 9ERV/1/Cj'/q ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDREBB/oR APNI A'- . r. /(JV CITY N.G OL(I,C`� ` PARCEL e1ZE/APNI <br /> OWNER'S NAME �C' V\ ADDRESS _ p JIA.. PHONE# l <br /> CONTRACTOR C.-(- ADORES G NC:132" MONEI 7 yL <br /> Aug CONTRACTOR ADDRESS Me PHONE e <br /> TYPE OF/W1 ELI/MIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONNORWO WELL e ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL e J <br /> `•l�F/!�� P(N-11 nS,.1, M.P. DEPTH PUMPST. FIRST WATER LEVEL ON <br /> ❑YPE OF PUMP# A <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL e ❑ BOIL BORING <br /> ❑DESTRUCTION' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMEBTICBYIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELTVC DIA.OF WELL CASINO O <br /> ❑ MRLID/MUNIOIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT REAL PUMPED: ❑YM ❑N. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑N. 5 <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE RPE <br /> 5 <br /> PROPOSED CONtTRUCTIONIDNLUNO METHOO: MUD ROTARY AIR ROTARI' AUGER CABLE OTHER j <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APAICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULER AND <br /> REAVLATIONS OF THE SAN JOAQUIN COUNTY. NOME OWNER.OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OFTHE WORK FOR WHICH <br /> THIS PERMIT IS MSUEU,I SHALL NOT EMPLOY SONG SUBJECT TO WORKMAN'•COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB COMRACTAKI BIGNAT RE CERTIFIER <br /> THE FO '1 CEI IFY TNAT IN TIf ORM NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I BNALL EMPLOY PERSONS SUBJECT TO WORgNAN'e CO, P ON LAWS OF <br /> CA PNIA: THE 1118 C L IKf IN ADVANCE FOR ALL REOURE,pI�x�tlPElCT10Nrt AT IMp••61421. COMPLETE DRAWING AT LOWER ARE D. <br /> Sj%F—I A / �) <br /> Tills <br /> r // 2 c D.Is <br /> ROT RAM ROPE to BaNeI Bol.le 'le <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OA INiOroBED <br /> Z. OUTLINE OF THE PAOMRTY.GIVINO OIMENSIONS AND NORTH DIRECTION. EXPANSION OF$MADE DISPOSAL SYSTEMS. <br /> 3. DIMFNSIONED OUTLINES AND LOCATION OF ALL EXISTMO AND PROPOSED 1, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STnuc TUnE9.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY. <br /> I � <br /> o <br /> 0 <br /> T:�":�flSIES <br /> (�00 r vl lL`' - 11998 <br /> ^If11SEAVICF_S <br /> W , <br /> ...... HEALTH DIVISION <br /> 1/ DEPARTMENT USE ONLY <br /> APPIIa.tlon A..w I,f BY ` MN /Z <br /> GI.N ImP..IIeO BY O 14mP I�rP..IIPn SY I y� DFI. 7 <br /> u�R.�lwr XrFSS a Br o.l. <br /> Cmmm1.N.: <br /> ACCOUNTING ONLY: An), FACS <br /> PE COD- FEE IMO AMGU11i R[MTl[D PLASM RtC9Ve0 By GATE �T1eOLVICE rMG f M m INYOICE <br /> PUD Hee9h So" ErrArO. 173(1)97) <br />