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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 9$202 <br /> (209)468%UN <br /> 101-RUPOPABU PERMITEXPIRES 1 MR FROM DATE SSUE <br /> "lots In Trlplests) <br /> pPRICAI'ION DI FIEriE 01Y MAGE TO 7HE SIUf JOAO[ JrfiY f'QR A PL MI' Q CONRTFMT MOAN NEiAU THE WO Mf DERC�[/.THIS APPLICATION Ira MADE IN COMPLMJCE WITH SAN <br /> JOAMM GOUNTY TfTLL CHAPTER 9-111"AND THE ST AIDE OF SAN JOAOUN COUNrY FVSUQ HEALTH SERVICES,B1YEOf AmAL HEALTH DNIs10N, <br /> .IDS AOOIEE/A`7R / <br /> CfT'Y FARC0.sQEfAPMF <br /> OWr1ER'S NAME ADDRESS PHONE S V <br /> 1 � <br /> CDNTMCTOR� �. 1s Tr f10I'�If�o�j 7� <br /> sus CDNTRARTOR ADDRESS s PHONE J <br /> "n OF IIS [1M9M WELL 0 REPLACEMENT WELL 11 MONrtomm"mu'r ❑OYHER__ <br /> IAL wwALLATION ❑ WELL SYSTEM mrAIR ❑ CR0e84ONNECT WAM ❑ vAIUR EPITRAcirvm WELL/ <br /> ❑N..L a** H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL 6 <br /> nYPE of P15AF1 <br /> ❑ OVT-OF-f &VICE WELL ❑ GEOPHYSICAL WELL IF ❑ not SppW4 r <br /> ❑DESTlucnoN: <br /> O cQ s Nf A <br /> © NDUSTRIAL ❑OPEN Norma DIA.OF WELL EXCAVATION OM.OF CONDUCTOR CAMIG <br /> ZDG sTIcxwvATE YO<m^VEL PAGff/Ive aaeI2 TYPEOFCAWNGATf 7Jr'VC � DrA.Of WELL CAepMOL&PISl1CAmn*CIPAL LJ DRIVEN DEPTH OF GROUT SEAL _ _ IPECi1CAT10N_%/6 LCL <br /> ❑ RRISGATIONIAG ❑OTHER GROUT SEAL INSTALLED SY [Ac> ,G 5fRO1R$MND NAME <br /> ❑ MONNOMM GROVTMALPVMPED-OX.. ❑N. CONcwvEFEDESTALSYOWum13Y. (3 N. 8 <br /> AFPRSIL DEP►N lQd(NG CHESTER SOxN7OVt MPF _ a <br /> PROPOsm COMST11uGT1OWOMLl11fp MVHOIh MIA ROTARY AIR ROTARY AUGER _CABLE at11Hl�Ef/ i ll <br /> 1 F"FAY CERTIFY THAT 1 91AVE PREPARED TOSS APPLICATION AW-1 THAT THE WORK WILL K DONE N ACCORDANCE WWR SAN JOAQUIN CODNTY OIIDINANCES,STATE LAWS,AND RUISSAND <br /> TEGULATIONS OF THE SAN JOAOIIIN COUNTY. HONE ORMER OR UCENKD ADEM'$SIGNATURE CERT FES THE FOLLOYANG-.'I CERTIFY 7NAT N THE PERFORMANCE OF THE WORK FOR W MCM <br /> THIS PERMIT IS MOND.1 sHN1 NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEWA"M LAWS OF CALIFOR*A.' C[NfiRAC7DR'S HA■IVD DR M16-GONTRACTNQ sLW1ATUlE t;Elfi>fTES <br /> THE FOLLOWING: -I CERT THAT N THE PERFORMANCE OF THE W'%F K FOR WHICH TRIS PERMIT IS ISSUED,1 sHAAL EMPLOY PERSONS SU%JlCT TO TRORIOMAN's COMMOATNLN LAWS OF <br /> CALIFO T MUST C N ADVANCE RWI AMI,REOMM N At f MSiL?S. COMPLETE DRAWM AT LOWER AREA PRUIPIP , <br /> Dale <br /> PLOT MAN Or. ti&PW Seek 'M <br /> I. NASTIES OF STREETS OR ROADS NEMEST TO OR SOUHDM THE PRDPfR . S, LOCATOR!OF HOUSE SEWAGE DISPOSAL sYSTEII OR}ROIOSM <br /> E. OUTLINE OF THE PROPERTY,ORAMIG DIMENSIONS AND NORTH OWWCTION. EXPAN1pN OF SEWAGE DISPOSAL SYSTEM& <br /> S. DIMINGHY ED OUTLNES AND LOCATION OF ALL EXIVI'M AM PROPOSED S. LOCATION OF WELLS WRIRN RADIUS OF ONE VANDREO FIERY FT. <br /> STRUCTURES,SVC COVERED AREAS IIIGN As f'/4TfDSl,DRIVEWAYS,AM WALKS. ON THE PROPERTY OR ADJOINS0 PROPERTY. <br /> i <br /> . .... .. <br /> i <br /> E ' <br /> : .. ; .. . <br /> .... <br /> T14S�Il�C f51 <br /> .ti ..��HFc�..11 <br /> MON <br /> DWARTMWT USE OIILY <br /> APPEAL"Aa.Olr/ <br /> GFMA M..eapm+ft �PnnP�m ST Dow - <br /> Oeehu.Rhn Mune.Rlee _ <br /> Dec. <br /> 7� <br /> r5si <br /> D/ Fpr# <br /> T REMITTED . ASN RIM211 W SY DAt FFINSTXIMACE RE011EST RLSMTIER D vomlE <br /> Pub.Heakh Serv.-En*o.173(1" <br />