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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEI <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompMtB In TripRBnte) <br /> AP`UCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOA A PERMIT TO CONSTRUCT ANDIOq INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE MIS SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE!STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEDUCES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDnESSIOR APN# �1'1-f'1" IWY"1rI Te"(SII�IeL� (� �/ <br /> _ n CR+�y��-F� PARCEL BRF/ARIF pSl 4Cr2 <br /> OWNER'S NAME Y�`yY•(QyY11(� COvh )!2(' v1.,S/T�\- ADDRESS 'L3CO G -gym Edl COnwA IcA Z <br /> CONTRACTOR .I lll'ld "/ 1111 '1 IKc... {�I Qom, ■ NF�I.�I/��Z W�r( <br /> ADDRESSsa <br /> G r UCI T �lY1.Q) RDNF/l91 la)37Z- <br /> BUB CONTRACTOR ADOrUESS UC# PHONE# <br /> TYPE OF WELLIPUMP; NEW WELL ❑ REPLACEMENT WELL MONTORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> ❑ <br /> A YPE OF{LMR New❑RRPeir H.P. DEPTH PUMP BET ". FIRST WATER LEVEL O <br /> 11ow-or BEnVIGE WELL ❑ GEOPHYSICAL WELL I 11BOIL BORING S <br /> El DESTRUCTION- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION BPECIFICATION6 <br /> 9 / (q ( <br /> IINDUSTRIAL ❑ PL <br /> ONBOTTOM DIA.OF WELL EXCAVATION Z�It> An(JL21n A pHA.OF CONDUCTOR CASINO U{t <br /> El DOMEBTIC/1`I1IVATE ®GRAVEL PACK/SIZE TYR /1'VC OF CABINOl6TFEl �y� Pi DIA.OF WELL CAM" O <br /> 13 RA �O � 1(D �L,1`-(,/� <br /> PURLICUNICIPAL ❑DmWN DEPTH OF GROUT BEAT 2 / SPECIFIOMATION lw7 <br /> L PIIMPEp; I Vw�r1,\W CT9^� R❑ IRRIGAMNIAO OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME_hX-�16hE9 MONITORING [3,. E <br /> APROT DMR SLOCKING CHESTER RO%/BTOVE RPCONCRETEPEOEBiALBYDRILLER:❑Yw [IN. <br /> PROMISED COMSTILTCTONnB.WNO METHOD: MUD RIJTARY AIR ROUM—)( _AUGER CABLE OTNEq S <br /> I HEREBY CERTIFV THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN"AMIN COUNTY 0 SHAMES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWTIG:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS BRIBED,I MAU HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' COMPACTOR'S HIRING OR BUR CONTRACTING SIGNATURE CERTIFIES <br /> TIIE FOLLOWING: <br /> -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- TIIEIL//�S//D//S//A/y T MUST CALL 24 NOUIS IN ADVANCE FOR ALL REQUIRED INSPECTION'S AT BNIel 48J <br /> 8422. CCOOMMPETE GRA�MM AT LOWER AMA PROVIDED. <br /> qwS X (/JYE/(Z�7n�s[, ,• KYRIACnr�Tlll. <br /> YY�B��I U MOT PIAN(M.He Bowl&.Ie._,_�-_•le .ly /� Y^ �_ <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROIFITY. 4. LOCATION OF HOUSE"AGE MSMM SYSTEM OR M,,MMO <br /> 2. OUTLINE OF THE PROPERTY,OIVHNG DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2. DIMENSIONED ODULINFS ANO LOCATION OF ALL EXISTING AND PROMISED B. LOCATION OF WELLS WTHIN MRIDI OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AMA$SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PPOPERTY OR ADJOINING RIOPERTY. <br /> �oseFL�LArvc Lci rOP014 UVB WAfM WTAG WCL <br /> I <br /> LA V13 wL1LTos� 9 <br /> Lo+ ZIL01 <br /> R} T-me�# 40 J, <br /> z <br /> Ito <br /> DEPARTMENT USE ONLY 9 <br /> Avplleepnn Aeeevlerl BY�LYL 1____� Dw. I I� •� G,�,,�, <br /> Arw <br /> Orav1 Irnpr¢Ilon By D.L. Pmp Inepallen By <br /> D.He <br /> De.baetlor•tmee+rbr. <br /> D.I. <br /> cemmr.e.: ri. �l/ <br /> ACCOUNTING ONLY: AID# ll FAC# <br /> PE CODES FEEINFO AMOVNTREMITTED CIIECrjICAM1 RECEIVED BY DATE PERMIT/SERWCE REQUEST NUMBER INVOICE <br /> VIM <br /> Pub.Health Sew.-Enviro.173(3/96) <br />