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' APPLICATIOIEkfOR.WELLIPUMP PERMIT <br /> SAN JOAOWt1 ; ' , ; PUBLIC HEALTH SER <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKfDN, CA 95201-388 <br /> (2091 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR. FROM ITE ISSUED <br /> APPLICATION 16 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT <br /> ' ALL THE WOW(DESCRIBED.THIS APRI•TION is MADE IN COMPIJANCE WTTH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9I.1115.3 AND THE STANDARDS OO/FF1 SAN JOAQUIN COUNTY WBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOBADDRESSX)RAFNI ���/N c/pl,l ( Ok l0/E]H4 iJ✓`IJ CITYY fj✓2aCU ,1 ,(J /� PARCEL S¢EIAFNS <br /> OWNER'S NMIE nL e�ar/l�o('� �9/'j[(/G ADDflE562-.T 1Q(1�1441G/fFV 1lI l/✓' F /,n 1 PHONE/( �j18-37�-,4 dao <br /> CONTRACTOR [ t:gl;L Dr/1llV� i SP1 ADDIG66/V/�//IT ly(udllp aL. UCe .'?06 zcl( WIOnfE ydS_Q < <br /> SUB CONTRACTOR <br /> ADDRESS M/ <br /> IIqq MORE <br /> TYPE OF WELL/PUMP. 101 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTA TION ❑ WELL SYSTEM REPAIR ❑ CROS6{ONNER REPAIR ❑ VAMfl EXTRACTION WELL/ <br /> (TYPE OF PlIMP1 <br /> ❑N—❑R,,, M.P. DEPTH PUTAP ST FT. FIRST WATER LEVEL <br /> -- O <br /> ❑ OlR-0FSEflNCE WELL ❑ GEOPHYSICN WELL I ❑ SOIL BORING B <br /> 1-1 DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONFTAVCTON i PECIHCATIO F p t/ A <br /> 101 INDUSTRIAL q❑F OPEN BOTTOM DIA.OF WELL EXCAVATION R DIA.Of CONDUCTOR CASING <br /> ❑ DOMESTICTRIVATE ([]GRAVEL PACK/SIZE �f'2 TYPE Of CASINGISTEELrtNC Q Pyr,1 O <br /> �.iS�-{ P✓C DIA-OF WELL CASING ? /� O <br /> ❑ PUBUCRIUNICIPK ❑DRIVEN DEPTH OF GROUT SEAL ^ SKCIFICATION A <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY l/1••I(IG✓� GROUT BRAND NAME E <br /> MONITORING GROUT SEK FUMKD; ®Y— ❑N. CONCRETEPEOMALBYDWLLF0.❑Y.. ❑N. 5 <br /> APfTO%.DEPTH LOCKING CHESTER BGX OV,MK J, <br /> FHOPOSE0 CON/THUCTIONI DUNG METHOD: MUD MTAIEY_L/--AIN ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS AFFIJCATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY 3WINMCE6,STATE LAWS. <br /> AND RULES AND <br /> REGUUTIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE MUDWING:•I CERTIFY THAT IN THE KIVOIRMANCE OF THEWOW(fOq WHICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMKOY KB60NS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB{ONTRACTING SIGNATURE CERTIFIES <br /> TILE FOLLOWING: •1 CERTHY THAT IN THE PERFORMANCE OF THEWORKWORK FOR WHICH THIS KAMIT 16 ISSUED.1$HALL EMKOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS Of <br /> CKJfO1W1A.•//(�f1/�E APPLICANT MWT M Iq{pS 1N ApyAN F.Oq ML REQUIRED IN6P/EC^`TpW AT/12O614S6313]. COMPLETE DRAWING AT LOWER AREA PIgNOEO. <br /> slpT.ax /.0/OM FAL/LI1CY_i--P✓f-IFIJY/E/LNG///IY///1M TIo._I J el�!©�/.S� 0.'. IDIS _ <br /> PLDT FLAN IDI—I.6UI.1 SUM Ia <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PRDKRTY, 4. LOCATION OF HOUSE SEWAGE DISMSK SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE FFOPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIGPOSK""EMS. <br /> J. DIMENSIONED OUTUNE6 AND LOCATION OF ALL EXISTING AHO PflOPO6E0 S. LOCATION OF WELLS WTyHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DNVEWAYS,AND WALKS. ON TME PROPERTY OR ADJOINING PROKRTY. <br /> .. ...... <br /> Si Tom' <br /> DEPARTMENT WE ONLY <br /> APPIiuJan Anc.pld 6Y .3u-5 5 <br /> Gmul 1n. on BY D.I. Punp Il�pacoon By Du. <br /> Dsll�cllon Nvp.clan By <br /> D.I <br /> Comm <br /> ACCOUNTING ONLY: NO/ EAU <br /> K CODES FEE INFO AMOUNT PEMIRED CHECKIrCAFH RECOVED BY DATE PDMITIFDWICE AEG EST NMA6WI INvoICE <br /> �h01 CU 5 PILI L <ue -� Ioja S bfl C <br />