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APPLICATION FOR WELL/PUMP PERMIT ~' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)46&3420 <br /> NOIR-REFUNDABiE PERMIT EXPIRESCalmlilip f YEAR FROM DATE ISSUED <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAGULN COUNTY FOR A PERMIT TD CONSTRUCT A,1dOpq INSTAU THE 1NOR+C <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11 15.a AND THE ANDARDB O BAN JOAOUIIJ�COUTAL TH <br /> +75Z�5 4f, . DESCRIBED.sERV O.THIS APPLICATION IS MATE IN COAiPUANCE WITI1 SAN <br /> JOB AOORE89pq APNI ;JJ((JJ �p L}�n� D•n� y LIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OM910H. <br /> OWNER'S NAME /j� F� CFIY / `ZL- <br /> PARCEL SIZE/APN/ <br /> CONTRACTOR ADDRESS CJ <br /> 1 r �n �7 FHONE. 3✓� <br /> 9V8 CONTRACTOR <br /> AbTFIE7J/07� <br /> 99 lc.- �' rl" ucl371D <br /> AObREBg —PHONE I V642 674 <br /> TYPE OF P• [3 �l-----� PHONE l <br /> ~`•1WELL/PUMNEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ —~~ <br /> ❑ INSTALLATION ❑WELL SYSTEM AEPAIRIJOTHER <br /> : --� IJN.❑ ❑CAp88{ONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> fTYPE OF PUMPI �� H.P. <br /> ��— DEPTH PUMP BET FT ✓ <br /> ,I r ❑ OUT-OF-SERVICE WELL ❑ FIRST WATER LEVEL-- O <br /> �OEBTRUCTION:wfp {�V � =. / <br /> INTENs OA,. GEOPHYSICAL WELL N <br /> 'V 1 y /t❑3 SOIL ROBING <br /> S pE� TYPE OF ELI. /•/ Cri/lJ•/I/ � /I�G ./J 8 <br /> C RUCTION sp IFICARONS vy <br /> Q II, <br /> ❑OPEN BOTTOM <br /> bOME9TICApIVATE DIA.OF WELL EXCAVATION to ds ? <br /> -RAVEL PACK/BfZE A <br /> IJPUBLIC/MUInCIPAL 13 DRIVEN —'� TYPE OF CASING/STEEL/PVC DIA.OF CONDUCTOR CASINO A1?+- <br /> ❑-IRMOATON/AO IDEPTH OF GROUT SEAL_ DIA.OF WELL CASINO D <br /> ❑OTHER GROUT SPECIFICATION <br /> ❑MONITORIGROUT 6EAL INSTALL ED BY d� ( ^ rJ/I�lKN7 t <br /> OROUT BRA R <br /> AFPROX.DEPTH GROUT SEAL PUMPED: ❑Yr 13 me NO NAME <br /> PROPOSED CONS TRUCTION/DIULLING METHOD: MUD ROTARY CONCRETE PEDESTAL BY DRILLER:❑Ya• ❑N• S <br /> LOCKING CHESTER SO%>B70VE PIPE�� <br /> AIR ROTARY��_AUGER <br /> 1 HE9ESY CERTIFY 7NAT 1 HAVE PREPAAEb THIS �—CABLE S <br /> --��OTHER <br /> REGULATION9 OF THE SAN JOAQUIN AP'PLfCAT10N AND THAT THE WORK yy1 <br /> TMS FERAL Is 19 COVNTY, HOME OWNER OR LICENSED AGENT'S 81GNATURENCERTI IE6 THE FOLLOWING:9UEb,181LALL NOT EMPLOY PERSONS ANCE STI(BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND THE FOLLOWING; 'I CERTIFY THAT IN THE pEgFOgM SUBJECT TO WORKMAN'S COM WING:•1 CERTIFY THAT IN T RULES AND <br /> CALIFORNIA.' THE ANCE OF THE WORK FOR WHICH THIS PERMIT <br /> LAWS U CAUFORMA.• CONTRACTOA'g Mll OR SUB{p"ANCE OF THE WW'ORK FOR WHICH <br /> APPLICANT MUST GALL 21 HOtXW IN ADVANCE FOR ALL LIEOLRRED Mf PERMIT IB IB9VE0,1 SHALL,EMPLOY PERSONS SUBJECT TO WORKM RACYIHO SIGNATURE CERTIFIES <br /> 9lgnad X PECTIONi AT(20i"p�22 COM AN'i COMPENSATION LAWS OF <br /> b 4>4 CC�- PME DRAWING AT LOWER AREA PROVI ED. <br /> Tltla ��!/ y�� <br /> 1, NAMES OF111 <br /> STREETS OR ROADS NEAREST TO OR SOUNDING THEN FEto 9x•1.1 Ba•I• <br /> 2. OUTLINE OF THE pgopE PROPERTY. 'la <br /> 2. DIMENSIONED OUT •G1VINO DIMENSIONS ANb NORTH D1FIECTpN. -- 1. LOCATION OF HOUSE SEWAGE pISPpB <br /> STRUCTURES. LK•IF.S AND LOCATION OF AL1.EXISTING AND PROPOSED EXPANSION OF SEWAGE LOCA OfBP08 AL SYSTEM OR FROPGSEO <br /> URES•E'IClU0fN0 COVERED AREAE 9UC <br /> °..-.. ..;....•E.. i HUNDRED FIFTY FT <br /> H AS PATpB,Og1VEy/AYB,ANq WALKS• <br /> ON THE PROPERTY OR TION OF WELLS�NINIFIG <br /> . i......_ PROF'Eg7y. <br /> �� LTf�a=P/if rS <br /> o�N J <br /> PllBLIC r <br /> 5- <br /> D"ARTMEN7 USE ONLY 15 <br /> Pna.11an AeaaPt ar /Ito. / /0 �Z� `- <br /> fu1 IFNPecllen By A <br /> D•ta PI.nP InoPatlert By <br /> HTUCIIen f"011,00114"aCllan By Dole <br /> bola <br /> mmsAr <br /> ACCOUNTING ONLY: AIDI ` <br /> FACT <br /> PE Cc DES FEE INFO AMOUNT RENSTTED CNECK/!CASH pECBVED BY DATE <br /> P>TyNIT/SERVICE REOL,EIt NUMBER INVOICE <br />