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IN-:atvl 1 i c�cAM)17C_D gY. ko <br /> C-et)7o,�_I+,,j�cft-L PA N <br /> I -icer y APPLICATION FOR WEWPUMP PERMIT <br /> ;:r*E <br /> �i QLD J SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> D ENVIRONMENTAL HEALTH DIVISIONJUL 2 ]998 <br /> Z/v <br /> X04 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> k') ,J —i 7 4 L�' VD-j Cj� 209'466-3420 SAN JOAO?Jlla COUNTY <br /> HNVFPR011A+IE ITEM_HN SERVICEI�l1aN <br /> ACATO!1�11MU; lION•REFU1lbABL PERMIT EXPIRES 1 TEAR FROM bATEl3SUEb EAtTMI]pJ{CehA TO THE SAN JOAOUIN CO F q A PEFp.11f TO CONSTRUCT ANDIOR INSTALL TIME WORK DESCRIBED.THIS APPLRCATIGN IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY-MVCLOPMENT TITLE.CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH OMSION. <br /> ArDD Fir T M jfP► PV—WA- <br /> JOB f (] /1 <br /> ADDRESSOR APN v QAJ N�'� It,F ,D H-��i.� y67'�yt CRY LzJ-k'�H 1'�,�r PARCEL SIZFJAF449 515 <br /> S I`n-iTta <br /> OWNER'S NAM(Q �^ /V K..LJi IC-��L 1 ADDIEBe A C-fL-A-NLN T f41pNE r /Q rr�a <br /> CONTRACTOR L�& P D Q,I�.L, I,+ ADORESR � � pQ l �,&ojoLICr PHONE r`��� ��CI3 ! i. <br /> SUB CONTRACTOR <br /> ADI>.LEee Ucr_ PHONE r <br /> TYPE OF WE_LUPUMP; ❑ M WELL MOTOm"o WELL r ❑ OTHER <br /> ❑ L6CONNECT REPAIR ❑ VAPOR_EXTRACTION <br /> ACTION WELL/ J <br /> ❑New ,j�rl-r H.P. SET R_ FIRST WATER LEVEL O <br /> {TYPE OF PUMP) ��(,I I, I�'��/ f.� j a,_ `.j <br /> "1lyDl � QEDICAL WELL r BOIL.BORING (a ZG S <br /> ❑DESTRUCTION• WDrk b@in ,- wrthou <br /> INTENDED USE T �' CO IFICATIONS f A <br /> '' ` aI Kral[ /, ' <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM ,eAMI�.F AVATION 4 � DIA.OF CONDUCTOR CASINO O <br /> ❑ O0T+IESTICIPIBVATE ❑GRAVEL PACIISIZE_ TYPE OF ChBINdlSIEELIPVC DTA.OF WELL CASING D <br /> ❑ PUSI-M UNICIPAL ❑bs"" DEPTH OF GROUT SEAL _ SPECIFICATION �I► R <br /> ❑ MRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> ❑ MONITORING !1 F G%OVt SEAL PUMPED: [3 Y. [IN. CONCRETE PEbESTAL BY DRILLER:❑Y. ❑Na s <br /> APVMX.OETtH LOCKING CHESTER BOXMtOVE PIPE s <br /> FROPOBED CONBTRUCTIONIDLSLLTNG MV14OD: MUD ROTARY AIR ROTARY AUOER__>e _CABLE OTHER <br /> I HEI"Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT 1'HE WORK WILL BE DONE IN ACCORDARCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSEO AGENT'S SIGNATURE CERTIFIES THF ROLLOV010i'I CERTIFY THAT N THE PERTORMANCE OF THE WORK FOR WHICH <br /> TWO PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-@ COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTIHG SRLHAtURE CERTIFIES <br /> THE FOLLOWBIO.- -1 CERTIFY THAT IN THE PERF40AMANCE OF THE WOW FOR WHICH THIS PERMIT IS 18OWD.I#HALL EMPLOY PERSONS SUBJECT TO WOFIIMAN,e CONIrENSATION LAWS I, <br /> CAUFDTIPAk APPLICANT NIUB BALL 24 HOUSLS IN ADVANCE FOR ALL RtIlU`NRIM INBnC Na AT 12'"I 4ft.1422. COMPLETE DRAWING AT LOWER AREA PROM ED. <br /> ,� l <br /> elunea X 7154- �1 Dotr � l� <br /> PLOT PLAN Rhsw to Saslol Scala—i- <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAOE OISPOSAL SYSTEM OR PROPOGED <br /> 2. OUTLINE OF THE PROPERTY,WVWM DIMENSIONS AND NORTH DIRECTION. FKPANBIOH OF SEWAGE DISPOSAL SYSTEMS, <br /> 2. DIMENSIONED OUTLINFI AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WFLLS WITHIN RAOIUB OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.OKLUOBM COVERED ARILS SUCH AS PATIOS.DRIVEWAYS.AND WALKS_ ON THE PR4PERIY OR ADJOILBNO PROPERTY. <br /> x <br /> ... . .:.. <br /> Olt Pop <br /> J p ; a iv <br /> ... ... . <br /> ., <br /> .. , <br /> PAYMENT . ....:.. . <br /> JUL .2 81998 <br /> / <br /> SM JOAQUIN CC]UNTY <br /> � <br /> PUBLICONM>=M1lTAL.H ar <br /> HEALTH SERV f 4W moo/oN <br /> 0WARTMENT USE ONLY <br /> A•Fllostlon Aaea•taA By_ Dat* Atw <br /> atetR"pmtle ByOat. Punq Irirmwtlon By 7Nr <br /> o�lnutlon kwneatlo By Dot. <br /> s <br /> a <br /> ACCOtINTINO ONLY; AID/ FACT . <br /> FT_COOEB FEE INFO AMOUNT f1EMliiEO CHECKrICABH RBC9VE0 BY DATE ILSWBTKEIIVICE REQUEST NUMBER iNVO10E <br /> Doff <br /> Pub Health Serv.-EnYiro.173(1/97) • <br />