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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WESER AVENUE,STOCIKTON, CA 95202 <br /> (209)468-3420 <br /> ■OM-REFUNDABLE PERMIT PIRES I YEAR FROM ATE ISSUED 5D-11:6-37S.601 <br /> IGrWleta In TTPSahI <br /> APPLICATION IS HERE BY MADE TO INC SAN JOAQUIN COUNTY FOR A PERMIT TO CONSrFIUCT ANDMR INSTALL THE WORSE bESCRISED.THIS APPUCATN7N IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUI11'Y DEVELOPMENT TRUE,CHAPTER 9-1116.3 AHD THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOS AODRENWINI APN/ � CITY PARCEL BIZFlAPNI <br /> OWNER'S NAME ADDRESS PHONE P <br /> CDNTRSCTDR�y G. ADDRESS C 1 LOCI PAOTIE I <br /> SUBCONrR1ICTOII ,> ADORERS JLICI THOHEI <br /> FYPE OF nM&M MP: ❑ HWN WELL ❑ nmACEMENf WELL ❑ MONITORING%ELL• ❑ wmen <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS"OIINECT REPAIR ❑ VAPOR EXTRACTwm WELL I 1 <br /> ❑N.L Rsp.k H.P. DEPTH PLIAP SET RT- FIRST WATER LEVE! r O <br /> (TYPE OF PUMR - !L/► <br /> _ 131 T OU14W-•SER E WELL ❑ OEOPTrvSIGLL WELL 8 SOIL BORIWA 40 J S <br />` DESTRUC"ON! 1 f L! lI s <br /> E-1-01-0 r OF w CO TR Hon S I C ONI A <br /> ❑INDUSTRIAL ❑OPEN BOTTom DIA.OF YWLL EXCAVATION DIA.OF CONDUCTOR CASING D '� <br /> ❑ OOMESTIGPRIVATE ❑GRAVEL PACKISIZE TYPE OF CAMNGIIITEE1JPVC DIA.OF WELL CASINO O <br /> ❑ PIISUICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL Wf-CRICATION I �1 <br /> ❑ MFmGATIORUAG ❑OTHER GROUT SEAL INSTALLED BY --- --- GROUTT BRAND NAME E' A <br /> ❑ MONITORING enoVT BEAL PUMPED: ❑Yr ❑N. CONCRETE PIEMOTAL SY DRILLERR!❑Yw ❑N. 8 <br /> APPROX.OERN_ Lomr"a C"FeTER SOXISTOVE PIE S 1y <br /> IV FROROBINI tome. LICTIONIOMLLING METHOD-. MUD ROTARY AIR ROTARY AUOER _CAMAL OTHER ` <br /> 1 HEJWBY CERTIFY THAT I HAVE PREPAAEO THIS APPLICATION ANL)THAT THE WORK WALL BE DONE fN ACCORDANCE WITY,BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS;AND RULES AND <br /> IEOULATIONS OF THE SAN JOAQUIN COUNTY, "CIA OWNER OR OCENSEO AGENT'S SIGNATURE CERTIFIES THE FOLLOVANO:'1 CERTIFY THAT IN THE PFFFORIUAHCE OF THE WORT(FOR WHICH <br /> THIS PERMR IS ISSUED,1 SHALL NOT EMPLOY PERSgNB SUBJECT TO WORKMAN'S COMPSNEATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUO-CONTRACTMIG SIGNATURE CERTIFIED <br /> THE FOLLOVANG '1 CERTIFY THAT IN THE PERFORMANCE OF THE W'IPK FOR WHICH THIS PERSurr IS ISSUED,1/NICE EMPLOY PERSONS SUBJECT TO TIIOFMPAAN'S COMPENSATION LAWS Of <br /> CALIFORNIA.- AlPL/CANT T=LLVM IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 170111 440,M D. COMPLETE DRAINING AT LOWER AREA PROVIDED. <br /> fund X �71t1. & ji_fLI.L� b.N <br /> PLOT PLAN IDF.w to L`ooki Se.1. 't. <br /> 1. NAMES Or STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, r� A- LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PnOPOSED <br /> Z. OUTU NE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> S. DIMENSIONED OUTLINES AHD LOCATION OF ALL EXISTING AND PROPOSED ■. LOCATION OF WELLS VATHIN MONS OF ONE HUNDRED FIFTY Fr. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAVES. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> l � <br /> CMIN <br /> woo moll <br /> rE M ;S� .a11u M' <br /> - y FEIIffI A. � <br /> lc-- <br /> - <br /> AV ,. - <br /> .. ..: ISLAND a IDS La <br /> n1A 1 M3 <br /> h r3 . <br /> eD g .2 <br /> 0ld I .., <br /> � L <br /> i. r <br /> ..- .,.. �"� ', sNEw•lAT rN LOu15E .7 <br /> - DFLT <br /> n ntF <br /> 2.3 41. <br /> 000WAAD AV.a <br /> 3 .aeon ar d.� �- a „•..yt� l�� QIIfE .,..,.,.. <br /> 6 3 Id LLNE RPB Fa , ,DtsE DAM PAYMENT <br /> i t !' IRIS.[ <br /> S <br /> S Trac C a Vg .8 vo°c�iio�u yp -_�� S N-.' .... .. CC <br /> CEIVED ---- <br /> .., 7nru. <br /> urs Ton <br /> 24 1997 <br /> SAN JOAQUIN COUNTY <br /> ` PUBLIC HEALTH SERVICES. <br /> f DbAMMANT U1[ONLY '2-4 G� �] <br /> AppBanlen A.s.plsd ST 11 I D.I. �' r ! yI� Ars. r1 (40 IIS <br /> Maul A op tbn Bv� �fr.i Osl. S 9 7 Fk"p kwp.ff.n <br /> D—tn-th—lo-p..d—B <br /> b.t. <br /> Camrne.Mr: Aj'C Q�w 1 r0+1 T3'I G1f1'�A cS et rYL rN Z l r`f <br /> �n nirN7l��cS Ltse.�I -7—ZZ -`f r . araC' 01rnu-ko-5 .7 <br /> AccoUNtWa ONLY-. AIDr rAC# <br /> r'L� <br /> PE COOETi FEE INFO AMOUNT I'M' TTEO CHECKNICAAH RECEIVED DY DATE PETMIIIT/DERVIC@ REQUEST N WVOIC► <br /> 431.2 150,p 1 `7-f <br /> r. _, -� <br /> Pub.Health Serv--EnYirG.173(i/97y �0 <br /> `^'l`-J <br />