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TYM OF/WI ELI/MIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONMORINO WELL e ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL e J `•l�F/!�� PrH-11 FWPFI, M.P. IPL DIM" PUMP S�C� T. FIRST WATER LEVEL ON ❑YFf OF rui;P1 A ❑ OUT-00.6ERVICE WELL ❑ GEOPHYSICAL WELL e ❑ BOIL BORINO ❑ DESTRUCTION' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO O ❑ DOMEBTICBYBVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELTVC DIA. OF WELL CASINO O ❑ MRLIORMUNIOIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME E ❑ MONITORING GROUTREAL MNIPED: ❑YM ON. CONCRETE PEDESTAL BY DRILLER: ❑ Yr ❑Nv 5 APPROX. DEPTH LOCKING CHEBTER BOX/STOVE RPE 5 PROPOSED CONtTRUCTIONIDNLUNO METHOO: MUD ROTARY AIR ROTARY AUGER CABLE OTHER j 1 HEREBY CERTIFY TIIAT I IIAW PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULER AND REAVIATIONB OF THE BAN JOAQUIN COUNTY. NOME OWNER .OR LIOEN6ED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERfIFV THAT IN THE PERFORMANCE OF TILE WORK FOR WHICH THIS PERMIT IB ISSUED, I SHAH. NOT EMPLOY BONG SUBJECT TO WORKMAN -6 COMPENSATION "We OF CALIFORNIA.' CONTRACTOR'S HIRING OR Me CONTPACTAKI BIGNAT RE CERTIFIER THE FO ' 1 CEI IFI TNAT IN TIf ORM NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORgNAN'6 COMPFNB ON LAWS OF CA PNIA: THE 11PB C L� IKf IN ADVANCE FOR ALLREOURE,pI �x�tlPElCT10Nt AT IMS) 4801 2B. COMPLETE DRAWING AT LOWER ARE D. Sj%F—I A / ----)Tills r // 2 c Ovls RROBa OT AM Lto Nel Bol vle ' le I. NAMES OF STREETSIN OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR II10ro6ED Z. OUTLINE OF THE rNIORRTY. GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF $MADE DISPOSAL SYSTEMS. 3. DIMFNBIONFD OMLINFS AND LOCATION OF All FKIMI'Ma AMR R OPrYnrN t Inuinu n[... v..I. wmrvv OF n...11-- nm rt APPII..11— Aaaq GrvU ImOrrorlen U—Irr� E F—Mvw A[[OIMTIMO ONLY: I NDI I rACS 'PLICATION FOR WELL/PUMP PERMIT SAN,..wAOUIN COUNTY PUBLIC HEALTH SEI ,FS ENVIRONMENTAL HEALTH DIVISION RR9VLDSY 304 EAST WEBER AVENUE, STOCKTON, CA 95202 !O►re TIlO1VICl IMDIRtfMWlll (209) 468-3420 �� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TrIpReBltl APRICATION m HERE BY MADE TO THE BAN JOAQUIN COUNTY FDA A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOIEDE6CRIBFO. TIIIS APPLICATION 18 MADE IN COMPLIANCE WHIZ SAN JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 8-y1115.3 AND THE "OAF 8 B JOAQUIN COUNTY MBUIC Ham) LTTE SEAV/1/Cj'/q ENVIRONMENTAL HEALTH DIVISION. . JOB ADDREBB/oR APNI A'— . r iuV CITY N. G OL(I, C `� ` PARCEL SIZE/APNI OWNER'S NAME �C' V\ ADDRESS _ p JIM.. PHONE IF CONTRACTOR C.—(— l ADORES G HCIy2"PNONEI 7 yL Aug COMPACTOR ADDRESS Me PLIOME e TYM OF/WI ELI/MIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONMORINO WELL e ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL e J `•l�F/!�� PrH-11 FWPFI, M.P. IPL DIM" PUMP S�C� T. FIRST WATER LEVEL ON ❑YFf OF rui;P1 A ❑ OUT-00.6ERVICE WELL ❑ GEOPHYSICAL WELL e ❑ BOIL BORINO ❑ DESTRUCTION' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO O ❑ DOMEBTICBYBVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELTVC DIA. OF WELL CASINO O ❑ MRLIORMUNIOIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME E ❑ MONITORING GROUTREAL MNIPED: ❑YM ON. CONCRETE PEDESTAL BY DRILLER: ❑ Yr ❑Nv 5 APPROX. DEPTH LOCKING CHEBTER BOX/STOVE RPE 5 PROPOSED CONtTRUCTIONIDNLUNO METHOO: MUD ROTARY AIR ROTARY AUGER CABLE OTHER j 1 HEREBY CERTIFY TIIAT I IIAW PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULER AND REAVIATIONB OF THE BAN JOAQUIN COUNTY. NOME OWNER .OR LIOEN6ED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERfIFV THAT IN THE PERFORMANCE OF TILE WORK FOR WHICH THIS PERMIT IB ISSUED, I SHAH. NOT EMPLOY BONG SUBJECT TO WORKMAN -6 COMPENSATION "We OF CALIFORNIA.' CONTRACTOR'S HIRING OR Me CONTPACTAKI BIGNAT RE CERTIFIER THE FO ' 1 CEI IFI TNAT IN TIf ORM NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORgNAN'6 COMPFNB ON LAWS OF CA PNIA: THE 11PB C L� IKf IN ADVANCE FOR ALLREOURE,pI �x�tlPElCT10Nt AT IMS) 4801 2B. COMPLETE DRAWING AT LOWER ARE D. Sj%F—I A / ----)Tills r // 2 c Ovls RROBa OT AM Lto Nel Bol vle ' le I. NAMES OF STREETSIN OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR II10ro6ED Z. OUTLINE OF THE rNIORRTY. GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF $MADE DISPOSAL SYSTEMS. 3. DIMFNBIONFD OMLINFS AND LOCATION OF All FKIMI'Ma AMR R OPrYnrN t Inuinu n[... v..I. wmrvv OF n...11-- nm rt APPII..11— Aaaq GrvU ImOrrorlen U—Irr� E F—Mvw A[[OIMTIMO ONLY: I NDI I rACS PUD Heanh SON. - Em4rG. 173 (1)97) RR9VLDSY DATE !O►re TIlO1VICl IMDIRtfMWlll IMV01[t Pl CODU ![[IMO AMOUNPRVATT[D PLASM U � -1 3 PUD Heanh SON. - Em4rG. 173 (1)97)