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APPLiCATION'FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 398,446 N.SAN JOAOUIN ST.,STOCKTON,CA 86201388 <br /> (2691488-3420 <br /> ROR•REFUNDABLE PERMIT EXPIRES FAR FROM DTE 188UEQ <br /> Ir-mpfete In TripRwtel ;p <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A MWIT TO CONSTRUCT ANDAR INSTALL THE MOM OE@CRfBED.THIS APRICATON Is MADE W!COMPLIANCE WIT!{SAN <br /> JOAOUIN COUNTY OEVELOPmfw Trrtj.CHAPTER 8-111 S.3 ANO THE STANDARD8 OF SAN JOAOUIN COUNTY pU tjC HEALTH BERVICEB, 1 <br /> ENVIRONMENTAL HEALTH DIVISION. <br /> Jab ADpiEHeAR APIs !I� / c✓C"T I r Ht,$�' cmr �EN <br /> /�7j / /J PARCEL OIMAPNF C 7 /Vln <br /> OWNER'-NAME E_ fY RV h. & /✓'!l IS <br /> ADDlceeG �$/y� �ryE�. <br /> S <br /> CONTRACTOR M•�"L�Vn 1� '.'[Jw�<12 r -`ADDRESS NE <br /> �c e Jt llnG �� PHONE/ 2f'.2 3S6'I <br /> 8U8 CONTRACTOR I! �U r SryG�' <br /> ADDl — <br /> PRO ME 0 <br /> - D"Or ML"Od", ❑NEW WELL ❑REPLACEMENT WELL ❑MONlfOWNO WELL/ <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑ & <br /> CRO- CONNECT RE;;; 13 OTHER <br /> D N—❑Rap•i H.P. 13 VAPOR EOf7RACTON wEL1 f <br /> ITV'ITi OF PUMpI DEPTH PUMP DET—Fr. FIRST WATER LEVEL <br /> O <br /> / ❑OOT-OF.SERVME WELL ❑MOFHMeWCAL WELL 0 ❑ SOIL SOANIO . <br /> �DEerflacrlGN: �/t vr4 IL(�V/f' EVl X75 �c�<e ✓L e <br /> �T I E�vlIIT GYtcn o1G� <br /> NTdOW E OF ELL CON[n1UCN N[PECIFICATNINS 6 <br /> ❑INDUSTRIAL 11 OPEN BOTTOM L DIA,OF WELL EXCAVATION A <br /> ❑DOmESTICfivWATE MORAVFL PACR(SIZE a ��" DIA.OF CONDUCTOR CAenIl„�'. O <br /> . (3 PUSVGMWLICIPAL 13 DROVEN TYPE OF CASINalSfEEGpyC DLA,OF Wrtl1 CAGING�� O <br /> DEPTH OF GROUT SEAL M*CIFMATION <br /> 13WEMATONJAG 13 OTHER L I A <br /> GROUT IFIL WTBTPE Ft+BY GROUT DRANO NAME ✓17-p /V <br /> MaNTTORRIO .. �• i F <br /> Pm <br /> GROUT am �:❑Yro ❑NO CONCRETE PEDESTAL BY DRIMI R: <br /> APPROX. j _ - a <br /> LOCKING CM:eTFR BORIDTOVE RPF <br /> PROPOSED CONSTRUCTIONIDIMLNNO METHOD:MVD ROTAM S <br /> AIR ROTARY AUGER_ CASTE OTNE - <br /> I1 HEREBY CEPROY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT THE WOiEI WRL BF DONE IN ACCORDANCE WNH BAN JOAaRN COVNTY ORORIANCEe,BTATI AND RULEBrAND <br /> MB PETOHf OF THE SAN JOAOUCI COUNTY.HOME OWNER OR LICENSED AOENT'-MNATURE CENTIFIES THE POLLOVMG:'I CERTIFY THAT Wi THE pEry Vq.rANCE OF THE WDHc FOR WHICH <br /> T1AB PERMIT N ISSUED.7 eNALL NOT EMPLOY PERSONS SUBJECT TO WORXMAN'i COIAPdiATION TAWS OF CALIFORNIA.-CONTRACTOR'S HIIDNo HE PEFFG <br /> THE MLLGIMNG: •1 CERTOY THAT IN THE ISWORMANCE Of <br /> THE WOFx FOR <br /> WMCH THIS <br /> PEAMR le I@WED,I SHALL EMPLOY REReO R' HNONCT TO WOROMPAC M 9IC AtUREATION LAWS OF <br /> oNAN'S CIo BNINATVRE LAWi EF <br /> CALIFOPMA.• THE APPLICA/NT NFUST CAALL 41 HOU,ILB IM ANC[MIL ALL REaLTREO IN[P111TIONS AT 14061/-[yLt7.COMFLETE DRAWING AT LOWER AREA PROVIDED: <br /> eyrw x Sn.e rA e.1 •ll� . A �n.1. r 'c-f�o•[er 13'l-- . <br /> � 9 <br /> 1.NAMES OF STiDETS OR"GADS PIE 0407 PLAN M'—ro Baaty Say. • O A <br /> I OUTLINE OF THE NEAREST TO N AND NOR THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DMMM SYSTEM OR PROPOSED I <br /> PROPERTY.GIVING pMEN&ON9 ATIp NORTH Umrior," <br /> 4.DIMENSIONED OUTLINED AND LOCATION OF ALL EXISTWO AND pMpGSED EXPANSION OF eEWAGE OMPOBAL SY8'TEMS. <br /> STADt Pno'OICLUDWO COVERED AREA@ SUCH AS PATIOS.DISVIEWAYS,AND WALIL8. S. <br /> LOCATION OF WETLS WITHNL RAMUS OF ONE HUNDRED FWRYON THE FT. <br /> ---PROPERTy DR ADJORMNa PROPERTY <br /> 5t <br /> 5, <br /> w Al <br /> . - ..... �T 171.. ... .-... <br /> ..... <br /> ... ... <br /> J5 <br /> JWh� <br /> iv ;.. <br /> L44 <br /> 6 <br /> DePMTMdT W E OM.Y <br /> APgN.CN,AeoW d <br /> Or•Vw h.~k.BT pM• D.e• (J /� 4 ArM��--�^ <br /> P. <br /> Irr-acNen eT <br /> D�tnretbn IrrP L..SY oat. .. <br /> CanTerlb• <br /> Daft <br /> :1 <br /> ACCOUNTING ONLY: ADE . <br /> FACT I <br /> K CODES FEEINFO AMOUNTARB/WTTW CH !CASH RECOVED BY DATE . <br /> UL w Q Sad l91A[THERVICE REQUESTNUNISFq WOMB <br /> J � a <br /> 3 <br />