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4 asd o� <br /> APPLICATION FOR WELLIPUNIP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 358,446 N. SAN JOAOUIN ST., STOCKTON,CA 95201.389 <br /> 12431 469-3420 <br /> P� NOWREFUNDABLE PEAMIT EXPrRES 1 YEAR FROM BRIE ISSUED <br /> Y J <br /> WA mplete In Trokste► <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT To CONSTRUCT ANDrOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMA DANCE WITH SAN <br /> JOAQUN COUNTY DEVELOPMENT TITLE,+/CCHAPTER 5-1116.3 AND THE SANDT0 OF SNAJGAQUIU COUNTY PUBLIC HEALTH SERVICEER <br /> S,ENVONMENTK HEALTH <br /> JOB ADOESSATR APN/ 3 :21CITU' a_7 PARCEL SlMAPN/ <br /> OWNER'S NAME AODREaB r�77 m}0.�'/L� PHONE I <br /> CONTRACTOR L ADDRESBO♦ / pNDNE 'y <br /> SUB CONTRACTOR ADDRESS UC/ PHONE A <br /> TYPEOF WgMNMP. ❑NEW WELL ❑REPLACEMENT WELL ❑MomrTORCN a WELL• ❑OTHER <br /> s� //�,,,, ❑INSTALLATION ❑WELL !M REPAIR ❑CPD99{ONNECT REPAIR 13 VAPOR EXTIL4L'TIbN WCLLfi J <br /> ITVPE OF WAMYI ❑ Ir H.P OEpfH PIMP FIRS'WATER LLVEL'L <br /> ❑OUT-OP-SERVICE WELL ❑OEOPHYMALWELL0 ❑ son-HOPING B <br /> ❑DESTRUCTION: <br /> MTEHPW TYPE WELL 00S TRUC'17011 WM A <br /> ❑INDUSTRIAL ❑OPEN BDTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CA604G p ^ <br /> EfOOMESTIOlPRIVATE ❑GRAVEL PACXlBQE TYRE OF CABMOISTEELNVC GLA,OF WELL CASING p <br /> ❑PUBLICIMUNSCIPAI. ❑mvEH DEPTH OF GROUT SEAL SPECIFICATION A J <br /> ❑OMATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONITORING �7 GROUT SEK PUMPEb:❑YM OHe CONCRETE PEDESTAL By DRILLER:❑Y— 13 x. S <br /> API NIX.OWTM_ 1 -1 r <br /> LOCKING CHESTER BbxICTGYL PIPF� a Iy <br /> PROPDB®CONBTnuCT)ORIMfOLUMBI MBTNOO: MUD ROTARY_ AIR ROTARY AUGER CARIE bTHER <br /> I HECESY CERTIFY THAT t HAVE PREPARED TWO APPLICATION AND THAT THE WORK WU BE DONE N ACCORDANCE WITH BAN JOA13UW COUNTY ORDINANCES,STATE LAWS,AND RULES AND Al <br /> REGULATIONS OF THE SAN JOAGUIR COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURRE CERTIFIES THE FOILOW ING:'I CERTIFY THAT IN THE PERF`ORMMCE OFTHE WOW PORWMICH a <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PER"ONS SUBJECT TO WORKMAN'S COI I MI ATION LAWS OF CALIFORNIA.' CCNtRACTOR'S HIRING OR MU84MRTRACTI G SKIHATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPIDy PERSONS SULIECT 7'O W ORgAAR'S COMPOIB TION IAVYB OF - <br /> CALIFORNIA.* THE APPLICANT M W ALL 341IOLBLIR IN ADVANCE FOR ALL REQUIRED RLSppCTIONS <br /> AT L,AOOSyI 41104M -COMPLETE bRAWINO AT LOWER AREA PIOVQED. <br /> 07,67 Tide �O `!" 5 <br /> PLOT PLAN Mewm scao I;eIR •to <br /> 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OP THE PROPFITfV,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANBION GF SEWAGE OmppDaM oyeTEMS. <br /> s.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOAED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> ...... .... . . <br /> . - L . .:.. <br /> .. <br /> a <br /> JAN '2 <br /> V <br /> �p.. <br /> 34 L LI Ll <br /> 4f . .'.... VICfS '......:......'.. . <br /> IT <br /> DEPAITMENT UBE ONLY <br /> Apyieelen Ao qnW SY_ <br /> a4s��Grant Ir.Tpeetlen By V dIe PUUnP IrrPaUon 8y O.te ✓ <br /> Daauetlon IT+Pctlon&I <br /> Vele <br /> CemmerxR: <br /> ACCOUNTING ONLY: AID/ F4C/ <br /> PE COOIx PIE INFO AMOUNT REMITTED HEC ASN REC9VM BY DATE Pg IATI)AXIMCE REOMT MRadam INVOICE <br /> 9 703y <br />