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13T -w <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, 095202 <br /> 209 468-3420 <br /> NON-REFUNDAKE PERMIT MIMS 1 YEAR FROM DATE ISSUED <br /> IComplEtf In TfiplkaNI <br /> APRICATION 19 HERE BY MADE TO THE BAN JOADUIN COUNTY FOR A PERMIT TO CONSTRUCT ANdOR INSTALL THE WOW DESCRIBED.Title APRICATION IS MADE IN COMPLIANCE WDII SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 11-11 119.1 AND THE STANDARDS OF BAN JOAOUIN COUNTY NBLC HEALTH SERVICER,ENVIRONMENTAL$SALT"DM@IO .�` ^ �T <br /> �j� + PARCEL RUAM/ P li 1 <br /> 01pp11��REBeroRAPNE 23 -0�0-0� 239 �� 1 c!,,!,3r%3 <br /> LATHRvP E E <br /> F-O,MJER'S NAME T t of cR R>;C�A ATwN DtSr x�R Ea. <br /> fmT, PRON�Go►JSu2nlGtnitf2lN0E DNq34-1 <br /> J] 1C!4CI d ucE �I.J`T_1 <br /> TYPE OF WE NIP, ❑ HEW WELL ❑ mP CEMEW WELL ❑ MONITORING WELL/ L❑�OLTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ✓ <br /> ❑Nen❑R.FMr N.P. OEM"NMP MF—FT. FIRST WATER LEVEL <br /> (TYPE OF MMPI ❑ OVTCF-SERVICE WELL ❑ GEOMVBICAL.WELL I X BOIL BON[NOq T6`r V'J <br /> ❑DE6TE111CTbN: GW 1 w% N I GR L- <br /> INTENDED UfF TYPE OF WELL CO A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.Of WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ OOMESTCIRVVATE ❑GRAVEL PACK/SIZE TYPE OF CASUIGISTEELIPV��ICp..�� CIA.OF WELL CASING O <br /> ❑ NBM MUNICIPAL ❑OmVEN DEPTH OF GROUT MAL 4() SPECIFICATION R <br /> ❑ IRISGATIONIAO ❑OTHER GROUT SEAL INSTALLED <br /> �JB(V GROW BRAND NAME E <br /> ❑ MONITORING E1-F,,1 SNOUT SEAL NMREO:)4 Y. ❑Ne CONCRETE PEDESTAL eY DRILLER:❑Y. ❑Ne 5 <br /> APPROX.DLPTN (-1 V r—e yr LOCKING CHESTER SOXAPTOVE mm: S <br /> momoED COMfT1UC110NIdelUMQ METHOD: MUD ROTARY_AIR WTA Y AWES CADGE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APRJCATION AND THAT THE WOM WILL BE DONE m ACCORDANCE WITH BAN MAOUIN COUNTY OPD NI ES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN"AOLIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE MLLOWINO:'I CERTIFY THAT IN THE FERFORMAME OF THE WOM FOR WHICH <br /> THIS KRMTT IS ISSUED,10/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF CAMONNA.• CONTRACTOR'S HIRING OR RUBCOHTRACTINO SIGNATURE CERTIFIES <br /> THE V1 IEITTITIAAT PR =MCWOCPIERMIT 10 <br /> ISSUED. <br /> IHEMPLOY <br /> �MFIGGONN. �SUBJECT S ('SCON{ATION"WOOF <br /> FOTWIAi /�CALL VANE R ALL REO CTON/ DSCPOMNAT LOWER AREA PTEDAFF <br /> S.'-a i ✓ • <br /> l-� nB. .P�/'r f I(.l // V/L/'ll•( -PJ'V D.I. <br /> ROT RAN Ra Sa.1.l Se.Ie •Ie <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TNF FROPIEROI'ERTY. /, LOCATION OF MUSE SEWAGE DIBPOSAI SYSTEM OR PROMBED <br /> Z. OUTLINE OF THE PRORRTY.DIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DMSA L SYSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXIST"ANO FRO MO f. LOCATION OF WELLS WTFHBI RADIUS OF ONE HUNDRED FIFTY M. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WALILS. ON THE PRORRTY OR ADJOINIM FROfERTY. <br /> s � ArrA,CP Sire PLAa <br /> PAYMENT <br /> F. 2'fzvEn, <br /> �:PG�4198 <br /> Flo rJC1s61UIN <br /> -'GUN <br /> EN7gL REALiOF . <br /> • iFNT USE ONLY <br /> AeP11eF11en AwaplM BF Otte. Mr <br /> 96 O.ume.n lwn«O—R. /L�✓�{� �/-T� ,�L/ t _0.1• <br /> ACCOUNTING ONLY: AID/ FACS <br /> PE CODES FEE INFO P A)UNU IT Awl"FD OLIEOK MH RECEIVED ST' DATE PEAMITISERVICE REQUEST NUNISBA INVOICE <br /> Pub Health Sew.-Enwro. 173(1197) <br />