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io <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 398,445 X.SAN JOAOUIN ST,STOCKTON.CA 95201.389 <br /> 1209)489.3420 <br /> !NWREFUYDAREE ff"ff"PIRFA 1 YEAR FROM OATS MUED <br /> ICIBMIITI Is TNyIUrh) <br /> APPLICATION I6 KFIF BY MADE TO THE SAN JOAOUW COUNTY FOR A PEMW TO CONNSTALICT AND/OR INSTALL THE WOAC OESCNBED.TNI APPLNCATLON M MADE W CON1'UANCE WITH SAN <br /> JOAOUI7 COUNTY DEVELOPMENT <br /> ,TTLIE,CHAPTER$-111 S.S AND THE SfANOARDB AOUW COUNTY PUEM HEALTH SERVICES,ENVIIONNEYTALL HEALTH ONISMJN. <br /> JOS AOBDBRES&OR APM• A I 1- W) • � crFY Lo(�.� PAACEI-S12fJAP1•_ <br /> OIMNEW S NAME d, ADDRESS PHW. <br /> CONTRACTOP kT�,••OS ADDRESS 353 r, _ (V`OI J -PNOI'E•.CLL�lYL <br /> BUB CONTRACTOR ALM$@ LIU _�PINOIE <br /> TYFE OF WCL MP: N¢.N NAl1 ❑NPLACEMENT WELL ❑MONTOWNB WELL I ❑OTHHI <br /> ❑INBTALLA:ION ❑NIT.l1'-T—REPAIR ❑CRODSCONNECT REPAIR ❑VAPOR FJMW TION WELL I J <br /> A,..❑REPN, H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL O <br /> (TYPE OF R/1IP1 <br /> ❑OVT-OF-IER1sCE WELL ❑GEOPTYICAL WELL I ❑ SOIL wow I <br /> ❑OES'TRUCT10W <br /> A <br /> ❑WDUSTNAL &TOPEN BOTTOM DIA.OF WELL EXCAVATION_ - DIA.OF CONDUCTO/I CASINO O <br /> (3DGMEsT1CAKIYATE ❑GRAVEL PAmwE_ TYPE OF CASINOBTEEUPIAC ,� tyA.OF WELL CASING O <br /> ❑0/P{jSU PILL ElDAVEN DEPTH OF GROUT SEAL_ -1�LJLN T S.CNWATON <br /> IY MIOAT ❑OTHER GROUT SEAL.INSTALLED <br /> ,,,���P��(CB7LLLLLY������ (iQ.t\-C E--- - GROUT BRAND,NAME E <br /> R <br /> ❑MONOIINC GROUT SEAL PUMPED{Mw. ❑N. CONCRETE PEDESTAL BY D LE C3 N. S <br /> Ag110K.DLTTH LOCKNO CHESTER DOXtSTOV E PINE s l[� <br /> PROPOSED COMITNXTIONIDALHNO METIOD:/MUD ROTARY,�_�_�AIR sLTTARY AUGER r CAMt��URETI— ••,(�� <br /> I <br /> I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOAD WILL BE DONE M ACCORDANCE WITH SAN JOAQUN COUNTY ORDWANCES,STATE LAW0,ZW RULES APJ <br /> REGULAT10N6 OF THE BAN JOAOUIH COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTSIES THE FNiO WM:'1 CERTIFY THAT N THE PEFIFOAMANCE OF THE MIX POR WHICH <br /> f TIPS PERMIT W 1ISBUED,I SNAµNOT EMPLOY PERSONS SUBJECT TO WOPKMAN'S COAIFBMATON LAWS OF CAUFTNMNA.' CONTRACTOR'S WING OR BUD CONTAACTNO aONATtW CERTLRN <br /> j THE FOLLOWING: 'I CERTIFY THAT W THE POFORMNJCE OF THE WOAC FOR WINCH THIS PEP WT IS IISLN.D,%!MALL EMPLOY PERSONS SUBJECT TO WONSWAWS CO"PIN IATION LAWS OF<,E <br /> CAUPOfISA•- T ANT CALL K ADORN IN ADVANCE FOR ALL K*aUsaD INSPBOTONS AT LBBsI 1.0046b.CONEUETE DRAWNO AT LOWEA AREA PROVIDED. <br /> � D.1. <br /> PLOT PLAN PO t•8W.1 awl. -tet <br /> 1.%AMU OF STREETS ON ROADS NEAREST TO OR BOUNDING THE PTOFEKTY. 4.IACATON OF HOUSE SEWAGE DISPOSAL SYSTEM OR PPOPOBEO <br /> Z.OUi1 WE OF THE FROPERfY,OIW1G dNtlYBONS AND NORTH DOIECTION. EXPANSION OF SEWAGE DOPOBALL SYSTEMS, <br /> J.DIMENSIONED OUTLINES AND LOCATION OF ALL EXIBTNG AND PROPOSED B.LOCATION OF WEtL.B W ITNN RADIU6 OF ONE HUMDIa'D FMTY PT. <br /> WFIlUCTUIE6.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE P/gPflTry <br /> aAN JUAJ'uri�(.."v.;ry <br /> ... ,.. <br /> ' "'' "• ' PLIBCIC'H£ALTH'�ERVIC <br /> • . ; ...� . . �NVIRt)NMFi•NiALFiEf4LTHD1�16{OM• ....:.. .... <br /> .. <br /> O@ARINWT USE MY <br /> [A-",%M BYA— <br /> G—A MwPR*Low By - �^•-- Ort• P+uP 1trPw1len BT _PNO ✓' Qs <br /> D•.tr-0-NI..cUort Sr LW <br /> Gammon: <br /> ACCOUVflNO ONLY: NDA FACT <br /> R we" FQ INNO AMOUNT Ali ITTED CNBC /CASH swaVm sY DATS RRANraL NNYNCI <br /> v0 Lr 5 <br />