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I killAPPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201388 (209)4683420 a NOM REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED - IPATPINtr M TdpIiEMb) APPLICATION 19 HEM BY MADE TO THE SAM JOAQUIN COUNTY FON A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW(DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE MH SAN JOAQUIN COUNTY OEYMOWAE/N)ETT�IIT\\LE,CHAPTER S-111$.3 AND THE STANDARDS OF BAN JOAONN COV PV/BUC NEAITH 9ERNCE9,ENNflONMEMAL HEALTH MN910N. JOB ADOTR66/OR AMNI �y,CC) ��FLL /IT'^LL/�/, _CRY/ /�� TT/'�1 y1- CA SUVAPNI p DMER'BNAM/E/,,11fh �1 J�III V Lilmottc/L I�)i/12j6II, (jIAIA...F. L'V)0 C. 1V LI �1l yAGU `PT (��RIO ME IF2 CONTRACTOR LA)R k GG'I�1 IC-�lJJ1�.ii4&'&JAn �(. VI-L./-L:S. ,11Kl AOORE861�Z(L.I1 llM1YLML:1Q(.1 ET' C,y�1�LICA JV( VR IO M. ?33 -)?s SUBCONTRACTOR �`L��.�LL�VM l Y01010fler yiry C� A1NMUE.4tf( 4RTt RIC 7-s c FN.w.`6 �{7(e_ TYPBOF@CV.11 NFNWELL ❑REPLACEMENY.M MONITORING WELLA ❑OTHER ❑INSTNLATN)M ❑VhM SYSTEM REPAIR ❑CR069{ONNECT REPNR ❑ ,MD.mee"IOH VhLL I J ❑Nw 11 Rgell HE, BEER.PUMP SET FT. FIRST WATER a. O (TYPE OF MMI IN ❑OUT-0F 6ERNCE WELL ❑OEOMYWCAL WELLI � SOIL BORING .S B ❑DESTRUCTION' INTENDED USE TYPE OF WELL CON6Te1 11ON ffECIHCATIONY p I I �I q A ❑INOUSTWAL ❑OPEN BOTTOM CIA,OF WELL EXCAVATION MA. MA.OF CONW TORCH M NI(E D 11COMEBTICRAWATE ❑OMVEL PACXWRE TYPE OF C....1.TEEIRVC PJC, DIA.OF WELL CARING 7ej O ❑PURLIC/MUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION 1 SPECIFICATION R L ❑IRWGATIUH/AO �OTNEfl GROUT SEAL INSTALLED BY GnJMv(.yULZ OROLR BRAND NAME E 1!1 �AONRORIND ` ) OPOVT SEK PIMPED:Q Yee We CO-FIETERDISTALBYOWLIEko. ❑N. S AWPDX.GREW /J LOCXINO CHESTER RO.Mlet R{E� S PROPOSM CONST M"CNM1 WNO METHOD: MUD ROTARI AIR ROTAll SUMMER CAME OTHER 11 i I NEARBY CERTIFY THAT I HAVE ABLPAREO THIS APPN:ATMN AMR THAT THE NOW(WILL BE ME..ACCORDANCE WRH BAN JOAQUIN COUNTY Omme,:ES.STATE LAWS.ANO Mae AND PEOULATIONB OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S AGNATURE CERTRES THE FOLLOWING;1 CERTIFY THAT IN THE PEI VORIAANCE OF THE INORL MRNMICH THIS PEWAR 18 ISSUED,I SHAM NOT EMPLOY RR6ONS SUBJECT TO WOMMMAN'e COMPENSATION LAWS OF CAUFORNM:CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATUIR CERTIHE6 THE FOLLOWING: CERTIFY THAT M THE PERFOWAANCE OF THE MW FOR MICH THIS PIR UT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CNIFOPMA. THF PRTCANT V(.TM.ALL 23 MMB IN ADVANCE MR ALL BEOURM INSPECTIONS AT IMI 4411 L2E.COMPLETE OMWMG AT LOWER AREA PEKNDED. k Tine _ p«. I`7 19 PLOT MN Me-b6W.1.1. •H, LoI 1,NAMES OF STREETS OR ROADS NEAREST TO OR W UNDINO THE PPoRRTY. A. LOCATION OF HOUSE GRANGE DISPOSAL SYSTEM OR PROPOSED3.OUT IME OF THE RKRRTY,CRYING DIMENSIONS AND NORTH IREECTKN, EXPANSION OF SEWAGE UBPo6K SYSTEMS. 3.OIMEH610NED OUTLINES AND LOCATION OF ALL MISER.AND PMPOKD S.LOCATION OF MILLS YATHIN RADIUS OF ONE HUNDRED FIFTY ET. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS,AND VVMe ON THE AIOPERTY OR ADJOINING POMSTY. c...... i... .. .... UsT 1.0 sTR�( t I o I ._0 3i Q y N m+M R�40 1urt; D fJON p.Atel ( AaeA t 0VMEM"MT USE ONLY Applkelbn beep,M By� �/JlJY`J p«. Ker Greue 1-11k,BY D«e P e I--H-BY D«e Dr4rlbn FetpeeHen BY De, 1 Comm I' ACCOUNTING ONLY: ND/ FACT PE COD. FEE INFO AMOUNT ROMTTED H /CASH RECBVED BY DATE PFBMIT/SWINGE REQUEST NU M INVOICE I� I