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\�J APPLICATION FOR WELLlPUMPPERMIT �� Z�I 17 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 368,446 N SAN JOAOUIN ST,STOCKTON,CA 95201 386 <br /> (209)468 3420 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM RATE ISSUED <br /> [CampMta In Trlp[Igata) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTALICT AND/OR INSTALL THE WORE DESCRIBED THIS APPLICATION IS MAGE IN COMPLIANCE WITH SAN <br /> JOAGUIN COUNTY'DEVELOPMENT TITLE CHAPTER 9 1115 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY RJSUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION Y <br /> JOB wpaF S RAPNF rte• MPhPr ✓ CITY k I ^r/1'/- <br /> PARCEL S12E <br /> OWNER B NAME v 5JER5 <br /> CONTRACTOR s ADDRESS--& PHONES NE542-2777-2-3/l✓ ADDRESS 41S ei- EC/ pT04- <br /> t <br /> Sun CONTRACTOR �I q yy <br /> ADDRESS LPr d✓Q- / I <br /> P <br /> I� /, • PHONE F <br /> T_YR:OF WELL�MP ,,/V/�-�,NEW WELL 0 REPLACEMENT WELL L�MONROWNO WEAL �� ❑OTHER <br /> • INSTALLATION ❑WEL <br /> 13 New L SYSTEM REPAIR ❑CROSS.CONNECTREPAIR ❑VAPOR EXTRACTION WELL! <br /> Q Q R.PMfr H J <br /> frYP[OF PJMFy SE <br /> I-, DEPTH PUMP T_F7 FIRST WATER I. O <br /> 0 OUTdF SERVICE WELL ❑GEOPHYSICAL WELL E T-� <br /> 5 !.J SOIL BORING S <br /> ❑DESTRUCTION M • � ti <br /> yIIN.,TFNOEO ISE TYPE OF WELL CONSTAUCTION SPECIFICATIONS / ply <br /> . 11YIXleTRAI ❑OPEN BOTTOM f __.,,w DIA OF CONDUCTOR CASING Alt+ <br /> 1 A <br /> /�+�LO!•✓l pA•OF WELL E%LAVATION <br /> ❑DOMESTICIMVATE GRAVEL pACR1ST2F '4• TYPE OF CASINOISTEE7/pyC ~TT�'� D <br /> --��r } DIA.OF EVELL CASING D <br /> RRIGATIO NI 11 OTH EN DEPTH OF GROUT SEAL } <br /> L-1 IIWGATIONlAG SPECIFECATION JrM1.LK <br /> ❑OTHER <br /> ONRDRNG GROUT SEAL INSTALLED BY GRDUT BRAND NAME E <br /> R <br /> MGROUT SEAL PUMPED` ! PEO ❑Vr L' N. COHCgETE PEDESTAL 8Y DAIUFR.Ely. <br /> g <br /> APPRDX DEPfH LOCKING CHESTER BOXMOVE RPE <br /> PNOPDSED CON/TRLILTION/oRWNO METHPD MUD ROTARY AIR ROTMTY S <br /> AUGER X _CASEE OTHER <br /> I HEREBY CEATIFV THAT I HAVE PREPMVD THIS APPLICATION AND THAT THEWORE WILL BE DONE IN ACCORDANCE WITH SµJOAOVIN COUNTY ORDINANCES STATE LAWS ANp gVLFBµ0 <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY HOME OWNER EIA LICENSED AGENT 8 IFY THAT IN THE PERFORMANCE OF THE 114YJEc FOR WHICH <br /> SIGNATURE CERTIFIES THE FOLLOWING 1 CERT <br /> THIS PERWIR IS ISSUED i SLL HANOT EMPLOYi'ERSONS SUBJECT TO WORKMAN/COMPENSATION LAWS OF CALIFORNIA CONTRACTOR S IIIR,Q OR SUBCONTRACTING 6K;NATUgE CEA71FIE6 <br /> THE FOLLOWINO, I CERTIFY THAT IN THE KAFORMANCE OF THE WORK FOR WHICH THIS PERMR IS ISSUED I SHALL EMPLOY PERSONS SVBJfC7 TO WORKMAN a ANGCOMPENSATIONSICURE LAWS OF <br /> CALIFORNIA TA APPLICANT MDS CA�'/:rANO a IH ADVANCE FOA/ALL REQUIRED IN/SPPEECTIONS AT Iy29Y1 4aSJ4T� LO/MFRETf DRAWING AT LOWER AREA PROyIpED <br /> L.l �K/ S/ rIN. /'/7�!'C! Y <br /> —7 p u <br /> ROT PLAN IM—IM Sw1 <br /> 4 <br /> 1 <br /> 7 NAMES OF STREETS OR ROADS NEAREST TO OR HOUNDING THE PROPERTY to <br /> 2 OUTLINE OF THE PROPERTY GIVING DIMENSIONS AND NORTH DIRECTION 4 LOCATION OF HOUSESEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 3 DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND RWPOSED EXPANSION OF SEWAGE WSPOSAL SYSTEMS <br /> STRUCTURES INCLUDING COVERED AREAS SUCH AS PATIOS DRVEWAYS AND WALKS S LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br /> ON THE PROPERTY OR ADJOINING PW-PERTy <br /> ' I , <br /> DEPARTMENT USE ONLY I <br /> ApPlk.tian Ao..PI.e BY— D-2 9 C� <br /> Nr�L <br /> OrwA I,NP.�DM B1 OMq �PumP Nwp.ellpn By - � <br /> DMR. <br /> D-o-d n LrP.cuw1 BY <br /> D.I. <br /> P I <br /> ACCOUNTING ONLY AIDS <br /> FALF <br /> PE CODES FFE INFO AMO LINT RIMITTEO CC KIICASH RECEIVED BY DATE PWAIT!/FANCE REOLIEIT NRAyIaER INVOICE <br />