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� I <br /> C <br /> APPLICATION FOR WELLJPUMV0i'VhIT 1[ <br /> j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 952021, <br /> iii (209) 46&3420 ? If <br /> ji; N0N-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> ij ICOmplets M TrIplkBtel . " ii <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOWC DESCRIBED.1TII8 APPLICATION 18 MADE IN COMPLIANCE W(TH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY fdBIJC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AUDRE88/OR APN/ J CITY ! `r��-!� - !! _PARCEL SIYE/APNF J'4A <br /> - <br /> r �r i � Pl <br /> OWNER' <br /> PHONE!e � L � <br /> coNTR!/r+ctoR �iS�•y . �L/rLd yADOREeB3PcMiil 4 LicarRHONE# ly•3S7 <br /> ]F /_ UCr PHONE F yg ytyD <br /> RUB CONTRACTOR AbDREBB <br /> J. <br /> TYPE OF WELt/ MP: ❑ NEW WELL ❑ REPLACEMENT WELL OmofwG WELL M I�- ❑ OTHER <br /> W <br /> ❑ INSTALLATION ❑ C <br /> WELL SYSTEMrRE!i ❑ CROSSCONNECT REPAIR 13 �VAPOR EXTRACTION WELL I J <br /> I <br /> 13 N.©Rmtth N.P_ �� 'E DEPTH PUMP SET FT.: FIRST WATER LEVEL 0 <br /> (TYPE OF PUMPI <br />�- jf;• 'S ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I X.BORING B <br /> ❑DEST'RUCTMN: 'F .: 'Ir. <br /> INTENDED USE TYPE Of WELL !i1 CONSTRUCTION SPECIFICATIONS A <br /> ik ih <br /> ` ❑ INDUSTRIAL ❑OPEN BOTTOM - VIA.OF WELL=EXCAVATION i{ DIA.6OFCONDUCTOR CASING O <br /> ❑ DOMESTK:MMVATE ❑GRAVEL PACKIBIZE TYPE OF CASINO/STEEL/PVC tf DIA.OF WELL CASINO D <br /> ❑ PUB:tICIMUNK:IPAL ❑DRIVEN DEPTH OF GROUT SEAL !: 'I STfCIFICATGON R <br /> ❑.IRRIGATIONIAG ❑OTHER aRDUT SEAL INBTAU.ED BY �I GROUT BRANQ NAME E <br /> I1 .l E I <br /> 1 <br /> 11 MONITORING r - GROUT SEAL PUMPED: ❑Yee 1114. ''i CONCRETE PEDESTAL BY DRU ER:❑Yw ❑Ne 5 <br /> APPROII.D EEPTH Z� �g LOCKIIM CHESTER SOXMTOVE PIPE jf S <br /> k PROPOi=COTIN <br /> ISTRUCTIOOI ILLINO METHOD; MUD ROTARY 4 AIR ROTARY AUG 11 '',� CABLE -•! OTHER —rr <br /> 1 HE+1EBY CERTIFY THAT 11IAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQVIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE F61-11 OI-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />{ THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS 017 CALIFORNIA.' CONTRACTOW9 HIRING OR SUB-CONTRACTING SIGNATURE CERTrMB <br /> THE FOLLOWING: 'I CERTIFY THAT M THE PERFORMANCE OF THE WOW FOR WHICH THIS Pli 18 MOVED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORNIA.' T ANT T CA 24 Fig ADVANCE FOR!ALL REQUIRED SNSPWTgNs At 12001 4MA6". COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> ji <br /> r � ��� TIHe f. ��f7_'Iy___�— x-��-1—� - - - ---------Date <br /> ,. �'� <br /> /LOT RAN ID,t4w to Bade/8aa1e •to ff �. / ,§ . <br /> 1, N B OF BTREET8 ADS NEAREST TO OR BOUNWHO THE PROPERTY. �'s j 4. LOCATION OF HOUSE SEWAGE DISPOSAL EM ORRR///PROPOSED <br /> 2, OUTLINE OF THE PROPERTY,QIVINO DIMENSIONS AND NORTH DIRECTION, f EXPANSION OF SEWAGE DISPOSAL BYSTEMS. <br /> ], DIMEN8IDNED OUTLINES AND LOCATION OF ALL EXIBtMNG ANbi`PROPOSEtl o ii S. LOCATION Of WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,MICLUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ` ON THE PROPERTY OR ADJOINING PROPERTY, <br /> i <br /> .. .... <br /> ,i <br /> I <br /> ... ..,. <br /> i <br /> 'i <br /> . . <br /> DEI!ARTMEHT USE OILY <br /> L11 <br /> Applicatki{i"led By Date 7 � Arae <br /> clmm kwpwl"By Dote '� T4tmp klvv atlnn BY <br /> Dea�uetien Inepeetlen By <br /> �O <br /> ff 1 <br /> Cemm@4: p I <br /> ACCOUHTINO ONLY: MON .�II. �� FAcs <br /> k k <br /> PE C00ES EEE INFO AMOUNT REMITTED CHECK/1CABN RECEIVED BY DATE I Pff"TISERVICE REQUEST NUMBER INVOICE <br /> 356 -7 � <br /> 'F <br /> Pub HeiML Merv.-ElrvirO.173(1197) !i <br />