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li eo APPLICATInIy FOR WELLIPUMP PERMIT 3 _�
<br /> i SAN JOAQUI I NTY PUBLIC HEALTH SERVICES
<br /> ENVIRO'MNTAL HEALTH DIVISION
<br /> R0.BOX 388,904 EAST WEBER AVENUE,STOCKTON,CA 95201 88
<br /> (209).488.3420
<br /> LNI111-REFUNDABLE PERMIT EXPIRES 1 YEAR FRDM DATE ISSUED e2e)s—S �7 ;
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<br /> APPLICATION IB HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR APE rt TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIED.THIS APPLICATION IS MADE IN COMPLIANCE WrTH BAN
<br /> JOAQUIN COUNTY DEVELOPMENT TrTLE,CHAPTER 1 15.aa AANNb rr 67 DARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENMRONMENTAL HEALTH DIVISION,
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<br /> LB ADDRESSOR APH ( f� ��' �i crrTYy 4G) .� PAARCEL&2ElAiNI
<br /> VNER'B NAME A ¢ - onsl 661SJ's -,;�&) �, ��/7
<br /> CONTRACTOR 'O 7. 1'T - ADDRESS C)• • LIC#
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<br /> lmm0TEOFWEU/PUMP: ANEW WELL ❑REPLACEMENT WELL ❑MONFTORINO WELL# : ❑OTHER
<br /> C 13INSTALLATION ElWELL SYSTEM REPAIR Cl CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL/ ✓
<br /> I � 9N_❑RapNr H.P. DEPTH PUMP 8-LYE-. EL 'FIRST WATER LEV7�_ O
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<br /> j ❑OUT-OFSERVICE WELL ❑GEOPHYSICAL WELL I ❑ SOIL BORING d
<br /> DESTRUCTION: C_
<br />` INTENDED LIGE TYPE OF WELL CONSTRUCTION BPECIFICATIONS A�F
<br />`I INDUSTRIAL ❑OPEN BOTTO#.1 DIA,OF WELL EXCAVATION r.� DIA.OF CONDUCTOR CA/SING D`'
<br /> DOMESTICJPW VAT'E GRAVEL PACXISIZE 3 TYPE OF CABINOIS7EELIPVCL7 EG'. DIA.OF WELL CASING Df
<br /> L R1BUC/MUNICiPAL 13 DRIVEN DEPTH OF GROUT SEAL, SPECIFICATION 6+ N
<br /> I IRRIGATIONlAG ©OTHER GROUT SEAL SNOIALLED BV a I,_ GROUT BRAND NAME�111l.('yI— E
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<br /> LmNNORN[I GROUT BEAL PUMPED:JYr ❑Ne CONCRETEPEDESTALnVDR&UR12�'. ❑Na S,
<br /> bFlrH I 1 LOCKING CHESTER BOX/STOVE RIPEAFD CONSTRUCTWMN DwLLING METHOD: MVO ROTARY•_•AIA ROTARY AUGER CABLE OTHER
<br /> I HE.1 CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION A".THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OFIDINANCES,STATE LAWS,AND RULES ANdl
<br /> f--=g OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH
<br /> IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING SIONATUrU CEPRIFRE�
<br /> E FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS C,?.-
<br /> FORMA. ,
<br /> FORMA.' 7CM7 MU T C 41g11Re IN ADVANCE FOR ALL 11EOlNRED INSPiCTIONI![�T1Tf�lAG84 488a4a1,COMPLETE_pMWINO AT LOWER AREA PROD. [
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<br /> PLOT PLAN IDnw to eul•1 Berl• 't0 ••••—
<br /> NAMES OF STREET.OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I
<br /> OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. f
<br /> Dir,1ENMONEa OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE MUNDRED FIFTY FT.
<br /> STRUCTURES,INCLUDING COVERED MEAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. -
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