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J <br /> Coo <br /> APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 45202 <br /> (209)4613-3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IBompl{ER In TRipREBL{I <br /> APPLICATION 1911EM BY MADE TO THE BAN JOAGUtN COUNTY FOR A PER AFT Ta CONSTRUCT ANDIOR INSTALLTHE V40 W EIESCRIBED.TIRE APPLICATION IB MADE IN COMPLIANCE WNN BAH <br /> JOAOUIN COUNTY DEVELOPMENT TREE.CHAPTER 9-1115.3 AND TILE STANDAIOB OF BAN JOADUIN COUNTY PUBUC HEALTH SERVICFB,ENVIPDHWWAL HEALTH DIVISION. <br /> �n eY /� I//,�,E CITY R^PARCEL BISFIAtNE 1 <br /> JOB AOCMBBIOR APHF X11 - - - - I <br />` AbOREB{ /J�r PHONE/ <br /> OWNER'R NAMEyJ /' /+y e/ <br /> CONTRACTOR ADDHES{� „�l+'�+ `b-_-UCr NJ 7 T!O Z^'PHOTIE/{J�•T�f J� <br /> ADORES S LICE PHONES <br /> HIM CONTRACTOR 0 T-T T- <br /> TV OF WE P ❑NEw WELL QMa11f om"WELL <br /> ,--i REPLACEMENT WELL �❑ E ❑T,OTHER <br /> 11 INSTALLATION LJ WELL SYSTEM REPAIR ❑cRa S9CONNECT REPAIL R 1 VAPOR EXTRACTION WELL <br /> ew❑ W 1 'Y <br /> ❑NA- H.P. DEPTH Pp SET� RR L <br /> P , FIRST WATEEVEL 52 .I�" a <br /> HPE YOF MWMW --77���,, pump �0 BOIL BOWNa a <br /> LJ OUl-OF-RERVICE WELL ❑aEOPL1YBICAL VYELL <br /> Yps OP W GON►TRUC X{PECIFIN <br /> CAON{ A <br /> INIFJIOED 44E 7 ID <br /> - <br /> CON <br /> .❑,q�INDUATBAL ❑OPEN BOTTOM DIA.Of WELL TXCAVATION DIA.OF WELL CASINO <br /> CABTNG a <br /> 1lFbOMEBTICAwVATE ❑GRAVEL PACKMUE TYPE OF CASINO1sTE*LM`VC DIA.OF WELL CASINO - <br /> ❑F BIICRJUNSCIPAL ©OMVFN DEPTH OF GROUT REAL SPECIFICATION R <br /> ❑IFT{GATONtAG ❑OTHER GROUT BEAL INSTAURORy D GROUT BRANNAME E <br /> ❑BgTOM <br /> RING ' GROUT BEAL PUMPED:0 Yr ❑N. CONCRETE PEbESTAL BY DRILLER:❑Vr l..l Na S <br /> LOCKING CIIEBIER ROXISTOVE flT S <br /> AlImma W.DEPTH_ - <br /> NMpoSTO CONSTRL/CTIOWMIRl LUl METHOD;MUG ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 mvwnY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THF WOM WALL RE DONE M ACCORDANCE WITH BAN JOAQUIN COUNTY ORGINANCEI,VANE LAWS,ANO RULLB AND <br /> fIEGVIATOHB OF THE BAN JOAaIWH COUNTY.HOME OWNER oR LICENSED AGENT'S SIGN <br /> CEITTNIEB THE FaLLOWANG:'I CERTIFY THAT M TRF PEPSOMAAHCE OF THE WGFK Fa11 WIWCH <br /> TWO PERMIT IB IRMAD.1 WALL HOT EMPLOY PERSONS SUBJECT TO YFOROGAN'S CONVEH{ATION U4VB>?f CALIFORNIA.-CGNTRACTOR'S NIBNG OR RV6COMRAe CO SIGNATURE CERTIFIER <br /> THE FOLLOWING: 'F CERFIFY THAT N THE PERFORMANCE OF THE WOM FOR WHICH TIBR PERMIT IB/BSUEO.I SHALL EMPLOY PERSONS SUBJECT TO WORIDAAM'{COM PER 01 LAWS oF� <br /> CAUFOBIIA.' TSI, AppUCANT MUST CALL M NOW III ADVANCE FOR ALL REGLRRfO fiM//�JP_EeTHING AT 12001 400.1428.COMPLETF DRAWING AT LOWER AREA/PROVR]EV. <br /> BRBrai <br /> PLOT PIAR 101ew le BeN-I BeN• 'to <br /> 1,NAMES OF RTRFFTS OR ROADS"FAR EST TO OR BOUNTIIHLT THE p"O ERTY. 4.LOCATION OF HOUSE SEWAGE OIRPOBAL SYSTEM GR PR0706EO !!! <br /> 1.OUTLNE OF HE PRGpumv,arAw OIMFNBRONB AND NORTH DIRECTION, EXpANRIOH OF BEWARE U40POM SYBTEMB. <br /> 7.DIMENSIONED OUTLINER AND LOCATION OF ALLEXISTING AND PROPOSED S, N THEIbN OF WEILB YVII'11PH RADIUS OF aNF HVNOII[D fIF7Y FT. <br /> BTRIICTURER.NCLUbING COVERED AREAS SUCH AB PATWe,DIEVEWAYB,AND WALKS, ON THEPP <br /> OR ADJOINING PROPERTY. <br /> 5 <br /> - <br /> r. . <br /> :. MAR... 3199TY9 <br /> ..-- `- .. ; HL! HEALPA <br /> 'N rINOT h F,NTALHEA T I:)lVll I)I' <br /> ....... ................. <br /> DE BE OWLY _ 3 A, <br /> AppINMI-Ae "BT ObN /9� <br /> OreVl I...Pmlbn BY a�R. Vl-ft 1-f..BT <br /> prwlnrtlNw I..rb�eRbn BY <br /> 1424.49 <br /> c,n.,.,....: W 51 L I N <br /> ACCGMIfN0 ONLY: AroF FACE <br /> PE CObEB FFE INFO AMOUNT RtlNITTE [CASH M1ECFNEO SY DATE PFMOTNFIMCF REOUFIT NUMB@I PMVa10E <br /> a 3 9 �r <br />