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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> !1011-REFDMIDARE PERMIT EXPIRES 1 YEAR FROM DATE 133 IED <br /> {Camplat•In vrk&stal <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A REMRIT TO CONSTRUCT ANDUOR INSTALL THE WORK MSCRIBED.TIRE APPLICATION 19 MADE IN.:OMPLIANCE WITH SAN <br /> JOAOUIN COUNTY MVELOPMEN7 TITLE.CH^AFTTER 9-1115.3 AND THE STANDARD/Of SAN JOAOUIN COUKI-YTPUBBfLIICC HEALTH SERVICES,ENVIRONMENTAL HEALTH CAVISgH, <br /> JOB ADDRE98AR AI'FIR, L, l _f VBA 'J Cj., �7 d�L�t/!LJ CMICv' ���/PARCCEyL SgE/A^F�N"f /t'` <br /> OWNER'S NAME ' ADDRESS 1-'.V 1](�7!�/q3O Jj IJC�dC_/C.IV rr444OORE ` 4,T — �. <br /> CONTRACTOR�� / //Orr�j' NE`s-!�!/ _ ADMA. w ) �1 C_.��11/ UC• PHONE# o_o C <br /> PUB CONTRACTOR !4}� - - - .. ADWIEB6 /y �/V LICa_ PHONE/ <br /> TYPE OF WELLIPUMP: LtJCJ <br /> ❑ NEW WELL ❑ FMACEMEHT WELL ❑ MONITORING WELL a kGTHER��� u— <br /> � <br /> f 94NBTAiLATR;N El WELL SYSTEM REPAIR 11C11099-CONNECTREPAIR ❑ VAPOR EXTRACTN/N WELLI ✓ <br /> f L11 N•wv❑RmW H.P, DEPTH HUMP BET FT. FIRST WA'fR LEVEL O <br /> (TYPE OF PUMPI �"� <br /> ❑ OUT-OF•BERWCE WELL 13 GEOPHYSICAL WELL I ❑ Sol!DORM g r� <br /> ❑OERTRUCTION: <br /> NTENDEO LJL TYPE OF WELL CONSTRUCTION aPECIFICATIDN J' A <br /> STINAL PEN BOTTOM DIA,OF WELL EXCAVATION f /J / OIA.OF CONDUCTOR CASINO p <br /> 11DOME91ICIPRIVATE ❑GRAVEL PACKMZE^ TYPE OF CASINOMIF.[LIPVC J d /`L. W7" DIA.OF WELL CASINO p <br /> 11PUBI.ICMUNICIPAL 10 DRIVEN DEPTH OF GROUT SEAL `7 O _ 9PECIFICAmm R � <br /> ❑IWRIGATIDHfAO t_.I OTHER GROUT SEAL INSTALLED BY OADUf 8RANU NAME E <br /> ❑ MONITORING �'y / GROUT SEAL PLIMPEO: CI Y•• 11N• CONCRETE PEDEBTAL SY DRILIER:❑Y•w (IN. S � <br /> AP X,DIFTH I�Q LOMI N3 CHESTER BOXISTOVE POPE s '� <br /> PROPOSED COMITRUCTIONUOFBLLINO METHOD: MUD ROTARY _AIR ROTARY AUGER_ CABLE OTHER <br /> I HMRV CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WOW WALL BE DONE IN ACCOROANCF WITH SAN JOADUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE IAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING!'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> TMS pE1VMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO W0kWARI'@ COMPENIATION LAWS OF CALIFORNIA.- CONTRACTOR'S MRING OR SUB-CONTMCTSLO SIONATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IFI TIREANCE OF THE YAM NOR WHICH THIS PERMTT 19 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPINIPATNIN LAWS OF <br /> M <br /> CALIFORNIA.' SNI APPLICANT MU@T CL 2247IN ADVANCE FOR ALL REGUIRfo ttwaP^FCT1ON/S7At 121401 4*0- 429, COMPLETE DMVNNO AT LOWER AREA ROVIDED. <br /> Sloned X TVH•- �.iVipil _ D--* <br /> FIOT PLAN lD•Mn to Sael•I Sai• "is <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAOE DISI M SYSTEM Oft FROMM <br /> 2, OUTLINE OF THE PROPERTY,OWING DIMENSION•AND NORTH DSECTIDH. EXPANSION Of SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED cUr"MF9 AND LOCATION OF ALL EXISTING AND PROPoem B. LOCATION OF WELL@ WITHIN RAMS OF ONE HUNDRED FIFTY FT. <br /> STMICTLSE@.Y CLUOINO COVERED AREAS SUCH AN PATIOS.DRIVEWAYS.AND WALKS" ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DeL Aft <br /> APR.17 1998.. <br /> + <br /> I ......�.............. .:..., .. : : : .,..... <br /> n, <br /> OEFMTMENT USE ONLY f.� <br /> Appksml•n A••epl•d ft— <br /> �/ 1 Dee• V ! V Aav <br /> G,wA 4"pomlon B,_ • �dqI.Npeell•n S ! D•l• <br /> Deanne.Imp•etbn BY ON• <br /> c•.nMenl. <br /> ACC0IMRING ONLY: MIDI FACT <br /> PF.CODES FEE INFO AMOUfIT�,rRN�ETc.MT7F0 eHEe%1 ASH RECEIVED aE OAT y Q TNER)1IeB Ummm INVOICE <br /> ;gq (CSV f I :s �0 C1 s'_ <br /> O�� O <br /> Pub Health Serv.-Enviro.173(1197) <br />