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APPLICATION FOR WELL)PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON.CA 95202 <br /> (209)468-420 <br /> MOM"REFUROARE PERMIT EXPIRES 1 YEAR FROM GATE IS4UE9 <br /> IGeg41.ILL 711pn.t.) <br /> APPLICATION IB HEF'E BY MADE 70 14C BAN JOAoUW COUNTY FOR A PERMH To CONBTRVCT ANDIOR IN67ALL THE W01K bf SCMIED.TAPS APPOCATiCH IE MAD!RI COMPLIANCE WRIT SAN <br /> JOAOUM COUNTY 1JEVELOFRFFN7 TILE,CHAPTERS 111 q THE STANDARDS OF iAN JOAOUIN CO MY r LPC HTEALTH SEEP/VICES.ENVIOUNMENTAL HEALTH DFN SIGN, <br /> JOS AOOREBS/OR APNX V— CITY r PAE1CFl eIZE/AP!1I <br /> OWFI[R'S NAME -ter ADDRESS PAONE f <br /> C t V <br /> COMRACTOM1 AOMESR LJC V PHONE <br /> ADB CONTRACTOR ADORE Se UCI F'IIOrIF f <br /> TYPE OF WfLL"mE,, ❑HEW W[Lt. ❑REPLACEMENT WELL ❑IAONTTONNO WELL I F1-1-I OTR_ <br /> ///�j �r/�} Y❑IFIET�A}1WITR N ❑WEAL eYSTFM PEPAML ElCr10SSt—NECT REPAIR LJ VAPOR[[TRACTION WELL! J <br /> ., DEPTH PUMP mu FT. FIRST WATcTEVE <br /> LL p <br /> TTYPF OF mw1 <br /> -oFi 1 E WELL ❑OEOgPHYBICu WELL f ❑ SOIL 00.NO <br /> IM TENDED USE TTP[OF WLAL COPMTRUC110R specIpIcAllams A <br /> ❑RRRFBTNAL ❑OFEN ROTTOM DIA.OF WELL EXCAVATION FAA.OF CONDUCTOR[AeRM O <br /> E3 OOUESTICA VATS ❑GRAVEL PAC+./SLIT_ TYPE OF CAINO/STEELPVC Of A.OF WELL CAGING p <br /> ❑IiFBIICMt1EaCTA1 F❑-I OPFVEN DEPTH OF GncO b4AL _ SEFCIF1CAr oN A <br /> ❑-I M.GATIOHIAD L�pTHER GROUT SEAL INSTALLED BY _ GROUT RRAND NAME E <br /> D MONFTORNO 0110VT SEH mtmpfom❑Y_ ❑N. CONCRETE PEDESTAL BY DMLEIC❑Yr ❑N. 5 <br /> AF X.OPTH r IOCKMG CHESTDI wxR oO lF4 5 <br /> PRO'N"M COMSTTHJCTTONFbNIUNO METNOOI MW ROTARY AIR ROT.Am ALNKn__CABLE OTHER <br /> — <br /> I HVW8Y CERTIFY THAT 1 PIAVEPRF►ARfp TMS ANUCATMN A A THAT THE WOW WRL BE DON[M ACCORDANCE WITH SMI JOAOUIN COUNTY OVIDNAFICES,STATE LAWS•ANO IEJLES AND <br /> PEGULATIONe OF THE SAN JOAgRH COUNrY.HOME OWNER OR LICENSEO AGENT'S SIONARW CERTIFItl T42 tVLLOWIW:•I CERTIFY THAT M TELE P[WORwLANCL OF THE WORK FOR WHICH <br /> THIS FERWI IS ISSVED,I BIFALA NOT EASLOY PERSONS SUBJECT TO WOAM.I.LN'S COMPENSAMM LAWS Of CALIFORMA•COI/TRACTOn'R HRSNO OR SIM LOMPUC PSA EDNATLRE CfDNR6 <br /> III[FO LA0: '1 CLARIFY THAT W THE PtRFoRMANC[OF TF1[WOFK TON WHICH THIS F"R IS ISSUET:,I WALL EMI'L.OY F[RSGHB SU64FCT TO WONN.AJI'S COM►Q/SATION LAWS OF <br /> CALK A. TI4C C MUST CA 4#10, III ADVANCE ELP A[L RE+IIwVD mNS AT jtF�ASA S 23,COMPLETE OHAMANO AT LOWER Al"Pno D, <br /> / , �T <br /> ` nor PLAN 10....f.B.Y.I 1Tc.1. <br /> 1.NAMES OF STREETI OR AOAOS WAFEST TO OR eoUNGIHo THE FPOT4FETY• .. ATION OF HOUSE SEWAW DFSFOSAL SYSTEM On PPOMgfD <br /> t.OUTLINE OF THE PROPERTY.GIVING OW"MONS AND NORTH[BIECTION. EXPANSDH OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DrMENSION[O OUfLINFS AND LOCATION OF All EXISTING AND PRJPOSfo S.LOCATION OF WELLS NTTTIRI RADIOS OF ONE HUHDrED FIFTY FT. <br /> STAUCTUTES,SA:LUDIFIG COVETED AEEaO SUCH AS PATIOS,bRVEWAYS,AND WA[ 3. ON THE PROPfRTYOR ADJOIIMU MOPfATY. <br /> a <br /> laD` a� Q <br /> 01 <br /> �A5, <br /> IJP r <br /> pLUC, <br /> . .. Jr.n J'�•rl.lU�f�.IVly i T <br /> TI;:.LJC-1:l,1_7ti Su��'iC!-S I <br /> [:"JIHOh!ri Elv"..4E.HEaLTh D........ <br /> OEIAAT iNT U.f ONLY C �I <br /> APPly.lbn A-1 of � �' - � 3 <br /> G:MA MPrirbn er_ �_ D.I.` F-1 InIP..�1en br D.I. <br /> II�In�Ilan I.+ne.lb..BF - O.Iw <br /> ACCO V1iIH0 ONLY: AJC/ FACI <br /> R COOS■ FTE INTO AWUNT AVATTFO "I.k CA.1/ R[CDVEG BY VA TC tl.10TVIC[REQUEST PNIOICE <br /> Pub H.Mh SGrv.-Envim 173(1.,W) <br />