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APPLICATION FOR WELL/PUMP PERMIT <br /> 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICemplata IN TrlpReatel <br /> APPLICATION IB HERE BY MADE TO THE BAN JOAMIN COUNTY FOR A PERMIT TO CONSTRUCT ANDNR INSTALL THE WON(DESCRIBED,THIS APPLICATION 18 MADE IN COMPLIANCE WDII SAN <br /> JOAOUIN COUNTY OEWLOMFNT//TRUE,CHAA"FR S-11115.7 AND 114E STANDARDS OF BAN JOAWIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODRESSDN APN/ L' CC S,6. /-<'642'OL— 2-r � PARCEL SIZUAMF <br /> OWNER'S NAME ,ji yyy�� }7'l�+iNl.Ct ADORE88 nn ��, ]JCR/YC1L_. RgNEI y <br /> COMPACTOR -LR1 AOOREBB�G) /'�'f'�lO ��A� ji� UCIH-Q9�:.Z <br /> PUS CONTRACTOR ADORF.BB UOI PHONE I <br /> TYPE OF WELLIPIIMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTAMA,TION ❑ WELL SYSTEM REPAIR ❑ CROSWCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> 'T-L ❑N—❑ReoFlr N.P. , DEPTH ROMP 8"2-61 . FIRST WATER IEVEI_3 O <br /> aYPE OF PUMPI <br /> ❑ OM-0E-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING B <br /> ❑OESTRUCTION: <br /> INTENDED USE TYPE GF WfLL CONSTRUCTION SPECIFICATIONS A <br /> A❑1 INWWRIAI ❑OPEN BOTTOM CIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> J6 MMFSTIOA'W VATS ❑GRAVEL PACKMIZE TYPE OF(ASINGIWEEIMIC DIA.OF WELL CASINO <br /> ❑ PUBLICAIUFRCIPQ El DRIVEN OEMH OF OROUT SEAL SPECIFICATION R `r <br /> Cl IRRIGATIONIAG ❑OTHER GROUT BFAI INSTALLED BY GROUT BRAID NAME E �F <br /> ClMONITORING GROUT SEAL PUMPED: 11Ys [IN. CONCRETE PEDESTAL By GRILLER:11V. Cl N. <br /> 5 <br /> APPROX.DEPTH LOCKING CHESTER BOXIWOW RPF S O <br /> PROPOSED CONITUUCTIONIOISLIING METHOD: MUD MTARY AIR ROTARY ANTER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS AFRKATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAQUIIN COUNTY ORDINANCES,STATE LAWS.AND RULES AHD <br /> MOLILATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR MENSFO AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMAME OF THE WORK MR WHICH f <br /> THIS PERMIT IS ISIUFO.I SHALL NOT EMPLOY PERSONS"ACT TO WORKMAN'•COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HIM"OR BUB,CONTRACTIM SIGNATURE CEDIRES <br /> THE FOLLOWING: -1 CER_TIf,Y,THAT M THE FEPFORNIANCE OF THE WORK FOS VMgH THIS PERMIT 18 ISSUED.1 SHAM FMKOY PERSONS SUBJECT TO WOPWAN'S COMPENSATION LAWS Olr:*K <br /> CALIFORNIA." TPI[ UNIT CALL 34 Mt"1'N ADVANCE FOR ALL REOU URS IM TONG AT IEDa14aSO4a. COMPI-ETE DRAWING AT LOWER AREA PMVIDED. <br /> SIP <br /> ROT RAN furor IB IMWO Ba.l. 't• <br /> I. NAMES Of STREETS OR MADS NEAREST TO OR BOUNDIM TILE PFK)M Y. 4. LOCATION OF MUSE SEWAGE DISPOSAL SYSTEM OR FEOPOBFD <br /> }. OPALINE Of THE PIIOPERTY,GIVMIQ DMfNBIONI AM MIRTH mI1ECTON. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> T. DIMENMNED OVTLNfe AM LOCATION OF ALL EXISTING AM PRgMBED E. LOCATION Of WIl M@ WITHIN MON•OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.IMLUOIM COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AM WALX8. ON THE RROPERTY OR ADJOINING PROPERTY. <br /> lei <br /> APz ? 7 1999 <br /> �11 � �7 DFPMTMENT USE ONLY ///-)�-// - (/ <br /> AMIIe.,b Aw.Pled 91 V �/ c V L/ O.1• ( C•l U Mr p `� <br /> Greu In.pM1I•n er o•I• Pune In.a.nnen ev DH• 8—/f <br /> Orwlnrclbn Irwn.atbn BY ON• <br /> 6 D ZAAb 5 <br /> ACCOUNTING ONLY: AID/ FAC/ ! F <br /> PE CODES FEEINFO AMOUNT REMITTED CHEC ASN RECEIVED aY DATE PERMIT IIERVICE REQUEST NUMBER INVOICE <br /> as i/a b 11 �Ut <br /> Pub �ealth Serv.-Envira. 173(1/97) <br />