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0 0 <br /> �Q CoP y APPLICATION FOR WELL/PUMP PERMIT <br /> U_ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> ��/� ,1 (209) 468-3420 <br /> ` E BLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> J (Complete in Triplicate]APPLI TION IS HERE BY MADE TO THE SAN JOAQUIN CO NTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER B-1115.3 AND THE STANDARDS OF BARN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> FJOB ADDAESSIORAM#• t4A<'a'Iz \• ` i-Di ( ISI L1IC'ogy q/rry/ `may LJ I PARCEELLSIIIZEIAPN! /( / <br /> OWNER'S NAME� I .b nL`iyz-ZIPIP I f OL<'1p 1 c_,K T L�'L� ADDRESS L.wi01 RJ( f /IJX�, Fn&9 ��)`/:t 1'-V R,IOiN'E'I ClyT�Z--T[J�47 <br /> COMMCTOR T `Y�/C�T'_YAA[ ADORE88 _P�'��C.C.yCi/ AVEl1CI ILIPIIONE/�✓/ Y� .XJ(J. <br /> HUB CONTRACTOR ...1y- y/- ApORE88 I��u � UC/ RHONE <br /> TYPE OF WEUJPUMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL! ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> (TYPE OF RUMP( 11 N.0FW..Ir M.P. DEPTH RUMP SET_FIQ EOTECHFIRST WATER LEVEL � <br /> gO <br /> DESTRUCTION: OU-OF-SERVICE WELL GEOPHYSICAL WELL! 101BbvLx1L=f'- l V�' L <br /> INTENDED USE w/Ak TYPE OF WELL N/F� CONSTRUCTION SPECIFICATION& NIX— A <br /> 13 INDUSTRIAL f ❑OPENBOTTOM f� DIA.OF WELL EXCAVATION Ian rL�QA j7Q('C,&� O <br /> ❑ DOMESTICIPIBVATE ❑GRAVEL PACK/BRE TYPEOFCASINOIBTEELIPVC DIA.OFWELLCASINO ••� D <br /> ElMRLICIMUNICIPAL ❑DRIVEN DI'.OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROVE BRAND NAME E <br /> ❑ MONITORING ;D •f ryry ^ GROUT SEAL PUMPED: 11Yf9jXRuILLI IV IE PEDESTAL BY DNLLER:❑Yr [IN. S <br /> APPROX.DEPTH 'J E71LI N Li S G.I P C.�/ LOCKING CHESTER BOXISTOVE PPE <br /> S <br /> PROPOSED CO NITRIICTIONIDNLInINO^M^ETHOD: MUD ROTARY AIR ROTARYAUGER�X CABLE OTHER <br /> 12i'L P'1li I��i ;&&U ,1 ED W 1-1-14 l'�F_n.1 f-\F j T [-I (LO LI'� 1 r' " _ . <br /> 1 HERESY CERTIFY TNAT I HAVE PREPARED THIS APPJCATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BA JOAOUIN COUNTY ORDINANCES,STATE IAWe,AND RULER ANO <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY, NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE STA E THE WON(FOR WHICH <br /> THIS PERMIT IB ISSUED, SMALL NOT EMPLOY PERSONS SUBJECT t0 WORKMAN COMPEHFATION LAWS OF CALIFORNIA.- CONTRACTOR-8 HIRING OR OUR COMRACTIN06IGNATURE CERTIFIES <br /> THE FOLLOWING: •1CERTIFY TNAT IN TIIE ERFOBMR E OF E WO OR WHICH THIS PERMIT 10 ISSUED.1 SHALL EMPLOY PEn60NS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' TNF AFPIICANT C Xe HOUR1 AD RACE F LL REQUIRED INSPECTION&AT IMS)44119 A23. COMPLETE DRAWING AT LOWER AREA PIgVIDE0. V <br /> 61.E X- L� //` TN. �iCl.l 1 C�(2. GYJ C:1 f/�J£-�1 D.,. �• �� '�y <br /> ROT RAN Id PE I.B.N.I 8aele •I. E� <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE R DIRECTION. <br /> S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PIIOPOSED <br /> 2. DIMENSITLINEONED <br /> OF THE RWRS ANRTY,GIVING ION OF <br /> AND EXISTING <br /> AN DIREOTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> ].STRUCTURES. <br /> OUTLINES AND LOCATION OF ALL E%18RNI AND IVEWAYS. E. LOCATION OF WELLS WITHIN RADIUB OF ONE HUNDRED FIFTY FT. <br /> FTPUCTVREB,INCLVOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PFIOPEPTTY, <br /> 1::iY7 <br /> \L <br /> . I HIL , I , `. I c� �.�, \A ,l( , r.lvl•`. <br /> Y ... .:............. . <br /> ( D TM TVSE ONLY 1� <br /> Appll..tlon Aaa.plM By I lU �� -24 / t <br /> D.I. <br /> G�.VI Ino«Ilan By D.t. OD R P In.P«G.n By <br /> Owe <br /> D,nNlgllpn InP«Ibn By <br /> D.Ie <br /> C.mmnn.: 4- 4h µ <br /> y �e <br /> ACCOUNTING ONLY: AIDE FAC! <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKNICA&H RECEIVED BY DATE PERMITISEIWICE REQUEST NUMBER INVOICE <br /> 5 <br />