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APPLICATION FOR WELLIPUMP PERMIT <br /> OAt1U1N COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N" SAN JOAMIN ST., STOCKTON, CA 96201488 <br /> (2091 488.3420 <br /> NONREFUNDABLE PERWr EXPIRES t YEAR FROM„SATE ISSUED <br /> {CSBI'Ish X0414111111 <br /> -?PLICATION IS NOW BY MADE TO THE SAM JOAOLNN COUNTY FOR A PERAW TO CONSTRUCT ANDADII INSTALL TNR WOISL DESCFABED.THIS APPLICATION to MADE IN COMPLIANCE WLTH SAN <br /> OAam CoUNTY DEvEiOFMENT TITLE,CHwm$-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY FULL=HEALTH SERVICES.ENVIAWWWAL HEALTH DIVISION. <br /> :OSADORESSMRA~ 501 South Lodi Avenue CTY Lodi{, C*A _PARCEL SMAPIM <br /> :vRMIEIR's ' C ADDREes_ .�S O SG+crP1LrlL lir..741Ot nn.CT I�FHONEl L`9,iT5 2M'c <br /> :oNTRACTOR Clearwater Groun. TOc= 1 1 25 At r „Ave_ - ate_ i f]2 'ucAtl amr_Aa PHONE _ 137 <br /> us UC* Gl.2C.IT * 8730 <br /> ?PE OF WEL.LMU110 © NEW WELL ❑ RFLtIJUcamw WELL MONITO1r110 WELL SjLjjjNW I+a❑ OTHER <br /> E7 IISTALLAum ❑ wwLL.svarEA REPAIR ❑ cmosecowwr REPAIR ❑ VAPOR EXTRACTION wELL s ✓ <br /> E3N.E3 Rod, H.P. DEPTH PUMP SET Fr. FIRST WATER LEVEL O f (1 <br /> YPE OF PUMP} �J <br /> ❑ oUTAFABERVIOE WELL ❑ GEOPlfYIRCAL was,• ❑ SOIL SORRNG g O <br /> 7 DEsrRI,crION: .` <br /> A <br /> 3 IISIUSTRIAL ❑OPEN soTTOM u DIA.OF WELL EXCAVATION /L DIA.OF CONDUCTOR CASING D <br /> 3y d <br /> OOMESTICN'ISVATE 10 GRAVEL PACKISD:E_ TYPE OF CASING IST DIA.OF WELL CASH <br /> J MKWJ UlMCIPAL 13RIVER DDEPTH OF GROUT SEAL SPECIFICATION 511A \\\ <br /> 3 IRRIGATIDWAG 13OTHER GROUT SEAL INSTALLED BY <br /> GROUT S MNO NAME Q E <br /> ?mowromm - GROUT SEAL PU MWP- WY. %M- RETE CONCPEDESTAL SY DfMLIER:WY-s ON. S, t\ <br /> Pp ox DIM (09 • LOCKBIG HESTER Bo VE PIPE_±_ __ S O <br /> WOPOM CONSTRUCM11IMMILL1NG Lh MUD ROTARY AMR ROTARY AUGER_CABLE OTHER fl <br /> 4VWY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOM WILL BE DONE IN ACCORDANCE WRM SAN JOAOUM!COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> :GULATIONS OF THE SAM JOAQUIN COUNTY, HOME OWMM OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PEIIFORMANCE OF THE WORK POR V N <br /> +RS PEMWT IS ISSUED,I*WLL NOT EMPLOY PERSONS SUR.IECT TO WORIM M'S COMPOWATION LAWS OF CALIPOR OA." CONTRACTOR'S HMRSYG OR SU6•CONTRACrM SIGNATURE CERTIFIES <br /> #FOLLOWING: "!ff T IN THE PIFORMAANCE OF THE WORK FOR WRAC"THIS PEIIMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAWS COMFSMSATKML LAWS OF� <br /> AUFORMIA." r. T CALL 24 HOLM IN ADVAMCS FOR ALL RSOUMSD WMWTIONS AT t2Wl4195-aM. COMPLETE DRAWBIG AT LOWER AREA PRD <br /> #,..X Tw. (cnyirc�nlrart�.i.� SZ&"i GkQaxtiA,tt�e�' Du. '. -7214 <br /> PLAT PLAN Mrwn to Scald Sods "to <br /> i. NAMES OF STREETS OR ROADS NEAREST TO OR BOUHMNG THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> :. OUTLLNE OF THE FROPI!R'rY,emm DMAENSIDNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> OIMEPMNONEO Wf BIOS AND LOCATION OF ALL E WMIG AND FIOPOM S. LOCATION OF RAILUS WITHIN RAORLS OF ONE HUNDRED FIFTY FT. <br /> STLIUCTURES.INCLUDING COVERED MEAS SUCH As PATIOS.DRIVEWAYS,AND WALK& ON THE F7ROPERTY OR ADJOBMG PROPERTY. <br /> f} _ <br /> ., ...1. ....i.. ! <br /> . 1 <br /> .PMoMNn AaoSpnd By sRWAR1TM®IT IMSOIILY D.R. 6 `_MEN� 8 <br /> �� v <br /> .rq", I ..., BY Dwbw P—p Irrprotlen BY <br /> '-trr�flen 4PwWo BY <br /> P1 ISLIr ��- <br /> VIRlaNt,.�CV� <br /> ACCOUNTING Imyt .. L= <br /> FACT <br /> t <br /> m CODES FUND" AMOUNT RBYITTIIO CHSCKSICASH ROCIEVED MY DATE PMMWMEWA=ROGUES.NUMIIBYI INVOICE <br /> 12:101 - <br /> a <br />