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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O•BOX 3K304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)4883420 <br /> RUN-REFUNDADLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> lls Iry <br /> APPICAiION IR HERE RY MADE TO TIIE FAN,In AOIIIN(Y111MVTon A Pf""PIDTO CONSTRUCT AND/On INREt ALL INF WOW r/FRL:RIRF.D.THIS APPLICATION Iq MADF IN COMPLIANCE Wllll RAN <br /> JOAOUIN COUNTY DEVELOnMENT TITLE,CHAPTER 9-1116,3 AND illf.STANARDS OF RAN JOAOUIN COUNTY PIBLIC IIEALIII SERVICER,ENVIRONMENTAL HEALTHDIVISION. <br /> JOB ADDRESSOR AE'NI_ CU <br /> clrr Trar�F C,� PARCEL BIZE/APNf233-460-07 <br /> OWNfn'S NAME_ Fonzia Corp. ADonE96 1001 Tahoe Blvd. 702-88.3-6161 <br /> ATONE f <br /> coErtnAc7oR_ V&W nr i 1 1 i n a ArynnERa p_(�- px 51 A n p;cl- UCf <br /> PUB CONTRACTOR -1uL�-19 AKONE fZD7-3 7d_7R15 <br /> ADDIFSS LICE PHONE f <br /> TYPE OF WELt/PUMP: O NEW WELL ❑REPLACEMENT WELL ❑MONAOnINn WFtt f <br /> 11 OTHER <br /> O INSTALLATION ❑WELL SYSTEM IIEPAIn O CROSS-CONNECT NErAIn ❑VAPOR EXTRACTION WELLf <br /> New❑ <br /> DYP ❑OF PUMP) Ileeeh N.P. DFM 14 PUMP aET_FT, FR�FIRST WATER LEVEL 0 <br /> DESTRUCTION- ❑DVI-Or SEnVICE WELL ❑OEOAIYSICAL WELL f I.71 BOIL SOMNG 12 <br /> R <br /> IN/ENDED it{E TYR OF WELL CONS/RUC ZION{PfCIFICAt10N{ <br /> ❑INDUS?SIAL A <br /> ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.Or CONDUCIO11CARING <br /> O DOME S TICR'/VVAIE OOnAVEI PACK/SNED <br /> TYPE OF CASINO/SIEfI/1'VC DIA.OF WELL CARING <br /> ❑PURLIC/1AUMCIPAL O DRIVEND <br /> r-� DEPTH OF GROTTO SEAL SPECIFICATION <br /> LJ IRNIGA7ION/AO OOTHER :ROUT SEAL INSTALLED RY R <br /> GROUT BRAND NAME <br /> APPRROX..Be" E <br /> ❑ O Be" Q SPROUT SEAL PUMPEO:O Ys ON. CONCRETE PEDESTAL BY ORILLEM O Ye• ON. S <br /> 1 <br /> LOCKING CHESTER SO%IR70VE AP <br /> S <br /> PROPOSED CON*T11VCNONIDRIIUNO METHOD: MUD FlOtAnYL.AIR RDTAnY AUGER CABLE OIHEq Hand auger <br /> I tIE7FRY CFnUfY THAT I HAVE PREPARED THIS ArTLICAUON AND THAT INE WORK WILL RE DONE IN ACCORDANCE WIT"SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> REOULATION"OF THE SAN JOAOVIN COUNTY,HOME OWNFn OR LICENSED AGEM'S SIGNATURE CERTIFIES THE FOU.OWING:•1 CERTIFY THAT IN THE PERFORMANCE OF INE WORK FOR WIOCII <br /> 11418rFnMIT IR ISSUED,I SHALL NOT EMA.OYPFRRONS RUBJECT TO WOnKMAN•{COMPENSATION IAWR OF CALIFORNIA.-CONTRACTOR'S AIRING OR @UK CONTRACTINO SIGNATURE CERTIFIER <br /> TIIE Font OWING: •1 CEI1rlF THAT IN THE PERFORMANCE OF TIIE WORK FOR WHICH TIIIR PERMIT IS ISSUED,1 RIIALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION <br /> CAUfORN1A.�`MI�AppU�ANT.t1r11J/F CA 71 L ADVANCE FOR ALL REQUITED INE►ECTION11 AT 1}0{1 46114421,COMPLETEMIM <br /> DNn AT LOWER AREA PROVIDED. LAWS OF <br /> SlfneA X Y CJL <br /> Oe1s <br /> PLOT PAN R)n I.%w.1 p­I@ b <br /> t. NAMER Or STREET*On RDAD*NFARFRT TO OR ROUNDINO THF PIOPRTY. <br /> �.OIIt LIN".of THEAIOP/RY,01NNO DIMENSIONS AND NORIA Dinrcl TIN, S.IDCAl1GN OF IIOIIPF SEWAGE.ry1gPOPAl*YPTiM GA AIOPO{ED <br /> �.DIMENSIONED OUTUNFA AND LOCATION of ALL EXtSTINO AND PKIPOFFD EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> STRLICl USER,INCLUDING COVERED ARFAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, S,LOCATION Or WELL@ WrTHIN NAD"/8 OF ONE HUNDRED FIFTY FT. <br /> ON THE PIOPRIY On ADJOINING PIIOPERTY. <br /> See attached map <br /> 1 <br /> Jf <br /> 1 <br /> : <br /> ... ... ... ... .o .. <br /> ..1...... .... . ;-.... : i <br /> DEPARTMENT USE ONLY <br /> OreU In•peetlen er-1! 1ti Del. ( p �(nP ln•Peeann 9y <br /> D.le <br /> ACCOUNIINO ONLY: I AID# FACE <br /> PE CODES rEE INTO AMOUNT PEMItIED IIECKf ASAI_ NECCIVED a DATE PEIPRU/*1011ACE nfnUE{T NUMBER INVOICE <br /> 3- 0 0 it 5 el, �d 1g� r, '7 <br /> Pub.Heetth Serv.-Enviro.173(3/96) <br />