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I APPLICATION FOR WELL/PUMP PERMIT ��,.,� r <br /> SAID JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON,CA 95202 <br /> (209)468-3420 <br /> ROM REFUNUPLE PERMIT IT EXPIRES 1 YEAR FROM DATE ISSUED <br /> lCom <br /> lets hi <br /> APR}CATION Ip NfPE BY MADE TO THE 6AN JOAOUIN COxist <br /> UNTY FOR A PERMIT TO CONSTPRUCT ANDXTA/INSTALL THE WORE OESCIUBEO THIS APPLICATION IS MADE IN COMPLIANCE WR II SAN <br /> JOAQUIN COUNTY DEVELOPMENT TEE7ACH'AP'TER 9 111 S 3 AND THE STANDARDS OF SAH JOADVIN COUNTY�EpusuC HEALTH SERVICES ENVIRONMENTAL HEALTH OIVIFIou <br /> I JOB ADORESBNOR ATN/ 1 <br /> J07--2 1- �/� vin, ✓ CITY / 14 YF 4 e ee, PARCEL B12E)ARlr ��3—0,� 1 j <br /> OWNERS NAME f YA I� �J"- <br /> /1 rr A7wnEsa pZ07 vS .lti,K Ma C PIDNEr 2DR <br /> CONTRACTOR G✓g Y11lI1+ A ,f �{n.T ADDRESS 750 W' RE Orf`ft UCN 511-15 PIONE/ <br /> FUS CONTRACTOR ADDRESS <br /> r-I <br /> UC/ ATONE r <br /> _TYPE OF W MP 0 NEW WELL ❑REPLACEMENT WELL MONRORNO WELL N 17A W ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑ CF43 CONNECT REPAIR ❑VAPOR EXTRACTION WELL I <br /> PUMP!-Nerr----FTFIRST WATER LEVEL <br /> ❑NµQ R.pp .1, H P DEPTH PUMP -- <br /> lTYPEPF <br /> I EIOUT�OFSERVKE WELL ❑GEOPHYSICAL WELL/ SOIL aORNO ��-1 I f <br /> ©btelnucnox � <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUC710H SPFCIPCAiI�`H <br /> ❑fNDUBTMAL Cl OPEN BOTTOM DIA OF WELL EXCAVATION DIA OF CONDUCTOR CASING__ _ <br /> I ❑ EIOMESTWIPRIVATE ❑ORAVEL PACK18121TYPE OF CA9INO18TfEVT'vC U C DHA OF WELL CASINO <br /> ❑r RLICMUHICIPAL ❑DRIVEN DEPTH OF GROUT SEAL Sr%CIFICATWH <br /> ❑ InRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY <br /> OAOVT BRAND NAME r-1 <br /> MOMrORINO ano UT SEAL PUMPED ❑VM [IN. CONCRETE PEDESTAL BY DRILLER❑Y- 0 Nn <br /> I AIPnOK DEPTH k h p LOCKING CHESTER SOXISTOVE PIPE <br /> rgOPOBFb CaN2rRUCT1ORfG`RLUNO METHOD MUD ROTARY AIR ROTARY AUGER_CABLE 07 HFR <br /> -n'eajjL Y CERTIFY THAT I HAVE PIEPAIIEO THIS APPJC ATgN AND 11HAT THE WOR(WILL BE IxINE IN ACCORDANCE NRTN BAH JOAOUIN COUNTY ORDINANCES STATE LAWS ANO nnLrS AN <br /> EnULATIO"I OF THE SAN JOAOUITf COUNTY "CME OWNER OR LICENSED ADEM S EIONATURET7CERTIFIER THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE or THE WCM Fon YNllrl <br /> THIS PEnMIT IB ISSUED 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENIAON LAWS OF CAUFORWA. CONTRACTOR I HIRING OR SUBLOHTRACTINO SIGNATUAF CERTIE IFF <br /> III FOLLOWING I CERTIFY THAT 711E PEIIFORMANCE OF THE L'YORL FOR WIRCH'HIB PERMIT IS ISSUED I SHALL EMPLOY PENBONI SUBJECT TO WORKMAN S COMPENBATIOK LAWS Or <br /> EAI IFORMA THE ►IKJCANT MUST�ALL 84 HOUR$IN ADVANCE FOR ALL 11EGURE6 INSPECTIONS AT I36814444435 COMPLETE DRAYNN0 AT LOWER AREA P1oV10EO <br /> RI.nM A <br /> TRI._._Zw1 YDNnw.+ I �l�+'.�.f. O1. <br /> ROT RAH gko. N 8..1.1 M.I------[ L { <br /> 1 NAMES Of STREETS OR ROADS NEAREST TO OR no LIMING <br /> THE PRO11RTY S LOCATION OF HOUBE SEWAGE DISPOSAL SYe1 FM an I apart r� <br /> T bUTHNE OF 111E PMPIRTy GIVING DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYST EIAs <br /> 7 DIMENSIONED OWrUNFS AND LOCATION OF ALL EXISTING AND PROPOSED ■ LOCATION OF WELLS YRTHRH RADIUS OF ONE IHUNnnrn rIFTY TT <br /> 0TRUC7URE8 INCLUDING COVERED AREAS SUCH AS PATIOS�DRIVEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY <br /> I II <br /> I I <br /> 4 I III <br /> ;- •� y�xlo.rdl � fi <br /> I <br /> IDEPARTMENT USE ONLY <br /> AO.IIe•rM�A.•..ld Sy 1-.1. MM <br /> n.w I n•.rrl..,Sr D.L. <br /> Pl.ry In.I..lr•n By O.r. <br /> Ir.+� �II•n I.vrnnb�Rr <br /> 1-.1• <br /> ACCOUNTING ONLY AID! FAC! <br /> J FE COOFA FEE INFO AMOUNT REMITTED CHECKNICAEH RECEIVED■y DATE POWNITISERMCE REOVEST NUNmSD1 INvorcF —� <br /> Pub Health Sery Enviro 173(1187) <br />