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I V.. <br /> 1 <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN JOAQUIN ST,STOCKTON.CA 96201388 <br /> (2091488-3420 <br /> i <br /> NON REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICompkb M Triplkltol <br /> APPLICATION IB HERE BV MAGE TO THE SAN JOAOUIN COUNTYMR q PERMIT TO CI N6FRUCT AN LMR INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEWLO%AERT TITL CHASTE 91116.3 ANDTHE <br /> STANDARDS OF BAN JOAQUIN COUNTY RUBRIC HEALTH SERVICES,EN SSONMENTAL HEALTH TY"MON. <br /> JOB AODRFSSMR SOME l <br /> /1 CIt/Y��e]I�Y! I � A \ PARCEL SIZE/AAI( <br /> OWNER'S NAME tk ADDRESS ('/'-�J11.(/] 4 I� � RHONE/ �1 <br /> CONTPACYOR AOOPE68 [ ' TIC, ATONE/�L'�C <br /> SUBCONTRACTOR ADORES. UC/ qq NEI <br /> TYPE OF WELLMIMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONRORINO WELL/ ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑C.......ECT REPAIR ❑VA FOR EIRMCTIOH WELL I J <br /> ❑Nen 0 RecA, N.P. GERM PUMP.ET_FT. FOUR WATER LEVEL O <br /> DYPE OF PIMP( <br /> ' 0DVT-0F6FPWCE WELL 0OEORIV6KAL WELL BOIL BORNO 6 <br /> ❑DESTRUCTION' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION. A <br /> 1:1 INDUSTRIAL ❑OPEN BO110M pA.OF WELL FKCAVATION � OIA.OF CONWCTORCABINO O j <br /> ❑OOMMMCIFWVATE- ❑SEEM PACKIBDE TYPEOFCASINOMITEELRVC DIA.OF WELL CAMIO D I <br /> ❑PUBVCIFROMCIPAL ❑DOWN DEPTH OF ODOM SEAL BRCIFKATKN N S i <br /> ❑IgWOATION/A. ❑OTHER GROUT SEAL INSTALLED BY SEDGY RAN." MF" MF 0'!'fI��E <br /> ❑FACED. .. 1 GROUT SEAL WARPED:O V., Q ❑He S ' <br /> ARAOX.DEPTH LOCKING CHEATER BOXISTOW RIE S <br /> M.M..CONITRUTEHYFUWHG METHOD: MUD ROTARY AIR FOTAPV AUGER CABLE OTHER <br /> 1 HP`RRY CODIFY THAT I HAVE PREPARED THIS APFLICATION ANO THAT THE WOR(WILL BE DONE IN ACCORDANCE WIT"SAM JOAQUIN COUNTY ORDINANCES.STATE LMW A AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWIN6:'I CERTIFY THAT IN THE IERFOOAANCE OF THE WOO[FOR WHICH <br /> THIS PERMIT 18ISSUED.I SHALL NOT EMPLOY MASONS SUBJECT TO WOOIMANY COMPdBAT10N LAWS OF CALIFORNIA.-CONTRACTOR'.HIRING OR 6U6 OWSACTIHO SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CEIDIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMR IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORW AN'B COMIEN.ATON LAW.OF <br /> CAUFOONI— <br /> T AMLCAHT MV TOGA(/U/.SEI HOURS IN AOVAMCE FOP ALL PEOIIIPEO IMIRC E,Mt�A,T�IEO/U^I�AMJ�.,Ei/..�COMyR�FJtTE d1AN'ING/AT�LOWER AREA PROW D/.� <br /> 6grcU v lA67 V� TRI.�� /T11'T�T/N'A�K / /1/ <br /> PLOT PAN 101.1.INNNI <br /> T.NAMES OF STREET.OR ROADS NEAREST TO OR BOUNDING THE RIORRTY. .. LOCATION OF MUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED2.OUTLINE OF THE PROPERTY,GIWNG DIMENSION.AND MONTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2.,DIMENSIONED OUTLMF6 AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS NTTHIN RADIUS OF ONE HUNDRED FIFTY m'. <br /> STRUCTURES;INCLUDING COVERED AREAS SUCH AS PATO..DNVEWAVS,AND WAV... ON THE PROPERIV OR ADJOINING ROPEIDV. <br /> 4,4 <br /> sw23 � <br /> a p <br /> �I� MwBD <br /> a.� <br /> DEPARTMENT USE ONLY ho-TsI14'^6 <br /> MSAF.lMnkWRM 0, C D.1. (^ ar 1 <br /> vk• . S P.RP IP.v..n..er DO. <br /> OVR,mn.e l,vo..nm ev Oi. . <br /> 6nmm.n,.: #- n .s a I a3 S iJEd Px C CIS 313 3 <br /> rnw35� mIA�gU �-�,�hS vvcaP�fe�Cl� �l5-�y <br /> ACCOUNTING ONLY: AID/ FAC. <br /> ASC... FROM AMOUNT REMITTED CHECKIKA6H REDFO'.SY DATE PDWIT..[ EPEOUGT NUMBED INVOICE <br /> �' 6 C `d3OOM '—VYIV-- -1 b_c $ I <br />