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APPLICATION FOR AELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 388.904 EAST WEBER AVENUE STOCKTON CA 95241588 <br /> (209)4154 3420 <br /> MOR REFUNDABLE PEWT XPIRf% 1 YEAR FROM DATE ISSUED <br /> 10Em0IBTB In 71*1H/BLP1 <br /> K ATgN IB NEAT BY MADE TO THE SAN- CI COUNTY EOR A PEFBMT TO CCNYTRUCT ANDIOR INSTALL THE WORK DESCRIBED THIO APPLICATION HS MADE IN COMPUAWE WITH SARI <br /> DUIN COUNTA <br /> Y DEVELOPMENT TITLE CHAPTER 9 1 1 1 S 3p/ANJD THE YTANDAPDO OF BAN JOAY IOUIN COUNTPJSUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> JOB AOOREOOMFt AMI ! r/ !r F .l (�!/ „�!/ C//CITY /L _ PARCEL Sl2EIARi1 <br /> OWPlFw O NAME_�"' /_ ` !_ r / ADDMOIS/ / e!I ✓ f 4/ / / 1 NE 1 Y I, a I` <br /> J� �! • I <br /> COWRACTOa / -r /I •'•••'_•••/ 7 ADORERS! !: / I LIC! / PHONE 1 <br /> WB COPTTRACTOR�/'./f{ Illi,r L W!^ _LICF _/ RroNE Irk%-1' et <br /> TYPE OF WELLRSIMP {❑1 NEW WELL ❑REPLACEMENT WELL k eEj,;o—OIONO WELL Or- Q ❑OTWER E <br /> LJ INSTALLAYMN ❑WELL OYOTEM REPAIR ❑CPOSs-CONNECT REPAIR ❑ VAPOR MRACTION WELL I r 1 <br /> ❑HwN❑R.P.k H► DEPTH PUMP SET_FT FIRST WATER LEVEL 0 <br /> rTYPE OF PVMPI <br /> ❑OIE/T-0E-sTRVI/C/E WELL ❑OEORfYSIcAL WELL S ❑ SOIL BOANO <br /> INTENDED USE TYPE OF WELL CONSTRUCTION BPECIFICATIOMS ' A <br /> ❑!INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION _I I _( DIA OF CONDUCTOR CASINO P <br /> ❑DOMESTICRRVATE ❑GRAVELP.CKMZE TYPE OF CANNO.TEELJPVC ! DIA OF WELL CAst D <br /> ❑NµIClMUN1CIPAL cl DRIVEN �^ DEPTH OF GROUT SEAL ~ SFECIF1CATION R <br /> ❑IPPPOATION/AO ❑OTHER f DRO,,SEAL INSTALLED BY OROUT BRAND NAME JF f <br /> ❑LIOMTORING ~ GROUT BEAL PUMPED ❑Y. ❑Ns CONCRETE PEDESTAL BY DRILLER❑Yw ❑N. S I <br /> APPROK DIEPTN y LOCKING CHESTER DOX STOVE PIPE S <br /> PROPOSED COMSTRLICTIONIORLMMO METHOD MUD VOTARY AIR ROTARY AVOER CABLE OTHER <br /> ) <br /> 1 HEAEBY CERTIFY THAT I HAVE PREPARED THIS APLICAMN AND THAT THE WOVE WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES AND I <br /> IIEGVLAMNB OF THE SAN JOAQUIN COUNTY HOME OWNER OR UCENBEO AGENTS SIGNATURE CERTIFIES TNF FOLLOWING I CERTIFY THAT IN THE KAFORMANCE OF THE WORK FOR VNGCH <br /> THIS PERMIT 16 ISSUED I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN S COMPQPSATIOM LAWS OF CAUFOPMIA CDNTMCTOA S HIMMO OK OUB-CDNTIUICTIND SKEHATURE CERTIFIES <br /> THE FOLLOVJRIO I CERTIFY THAT IN THE PERPOIMANCE OF THE WOW POR WHICH TWO PERMIT 11 ISSUED 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN S COMPO/SATIOM LAWS OF <br /> CALIFORNIATHE <br /> APPLICANT MUST CALL 34 HIOLAW FN ADVANCE FDR ALL REOUTAM INSPSCEIOW AT 17001440.1122 COMPLETE DMAM*OO AT LOOWER AREA PIONDED <br /> Hlyy%/ ( ,/ �/ TIN• r l r ! l J c>f -/ b•I. /!`�.• i <br /> PLOT AN LDI•w P• -. <br /> ` •AI Sul• la ` <br /> 4 NAMES OF STREETS OR ROADS NEAREST TO OR BOVRNOINO THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DIOPOOAL SYSTEM OR PROPOSED <br /> OVTUHE OF THE PROPERTY OMPO DIMEMNONS AND NORTH DIRECTON EXPANSION OF SEWAGE OIBROSAL SYSTEMS <br /> 2 DIMENSIONED OVTIIHFs AND LOCATION OF ALL EXISTING AND PIOMBED S LDCATON OF WELLS WrTWN RADIUS OF ONE HUNOPED FIFTY R <br /> 1 <br /> STRUCTURES INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS ON THE PROPERN OR ADJDININO PROPERTY <br /> I <br /> I <br /> 1 <br /> t <br /> DHIART TINT USE ONLY l <br /> LA.r-..n...A..�I.�er_/! 1 _!I_J I a J D•I. 1 i <br /> GM Ir�w.+�Br � D•t. It.n•YwP.r1�■r D•I. <br /> P�Irvlrn b—H—01 SOI. <br /> Crave <br /> 1 <br /> 1 ACCOVNTlka ONLY I —1 fACP <br /> tDOU FET INFO AAAOVKT k""M CMIC"MAJ. wFCOVTD ST DATE P TMPMCE PUOUElT NU ISM INVOICE <br />