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APPLICATION FOR WELLJPUMP 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 /> NONREFUNDABLE PERMIT FVPII ES 1 YEAR FROM DATE ISSUED <br /> ICompMN In TTip1k•ts) <br /> APf9.ICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOn INCTAIL TNF WOW DESCRIBED.71118 APPLICATION IR MADE IN COMPLIANCE VATII SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLES.CIIAPTER Bf-�1 1 15.3 AND TIIE GTANOAnDR OF BAN JOAOUIN COUNTY PUBLIC IIEALIII 9EnV10E8,ENVInONMENTAI HEALTH DIVISION. <br /> �}-a �_. <br /> I. <br /> — <br /> CITY PA(I(:El RIZF/AP(lIJOB ADDRESS/On APINA SG/ ICL f��.4- 1 7OWNER'S NAME n 1llLl I I lf AOORF 88 ,2A.11 NIONE P .�Rl,g�jJQS}—^SQ/(� l <br /> Pt <br /> CONTRACTon <br /> AiybC.ONTiV,CTOR (T Pn'1 P�Q1,�si�.� AO(N1f 88 �LSYfAfK IVB` 5�1.�.�+.UCl f110NE T <br /> (0 5�1 wMtse <br /> ❑ <br /> TYPE OF WELL/PUMP; p7�f✓NFW WELL ❑ nFPIACEMENT WELL ❑ MONITORING WELL O111En <br /> ❑ INSTALLATION ❑ WELL BY9TEM REPAIR ❑ CROSS�CONNFCT nEPA1n ❑ VAPOR EXTRACTION WELL I ✓ <br /> ❑Nww❑IMn�lr II.P, <br /> bEPT IT PUMP SET T. FIRST WATER IEVEI _ O <br /> (TYPE OF PVMPI ❑ OUT-OF-BEnVICE WELL ❑ GEOf•IIYSICAI.WELL/ ROIL BORING <br /> ❑DESTnUCTtON: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA HONS <br /> IA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> D <br /> ❑ INDUSTRIAL ❑OPEN no TTOM O <br /> TYPE OF CASINO/81f F1/F'VC DIA.OF Wfll CASING <br /> ❑ f10MESiIC/P+VVATE ❑GRAVEL PACK/SIZE R <br /> DEPTH OF GROUT REAL SPECIFICATION _ <br /> El f`VBLICIMUNICIPAL El bRIVEN ' <br /> ElInruGATION/AG El OTHER GROLIF REAL INSTAU.Eo BY GROUT BRAND NAME L 9_IVY P IT-� E <br /> ❑ MONITORING GrOUT RFAL PUMPED: ❑Y- LIN. CONCTIETE PEDESTAL BY DRILLER:❑Y- [IN. 5 <br /> LOCKING CHE91En nOXIBTOVE PIPE S <br /> APPf10X.ITF.PT H <br /> PROPOSED CONSTRUCTION/DIVLUNO METHOD: MUD ROTARY AIR ROTARY <br /> AVOER CARIE OTHER <br /> I lit-WHY CERTIFY THAT I IIAVE PREPARED T1118 APP(.roATION ANO TIIAT THE WOnK WILL BE DONE IN ACCORDANCE WITH GAN JOAQUIN COUPDY OROINANCES.STATE LAWS.AND RALES AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSto AGENT'R 9tONATUIIE CERTIFIE8 THE FOLLOWING:'1 CERTIFY THAT IN THE pERFOnMANCE OF TNF WOW FOR WIIICII <br /> 71118 PERMIT IR t681IE0,I SHALL NOT EMPLOY Pf.R80N9 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAIIfOfMA.' CONT MCTOR'8 HIRING OR AVR CONTMCTINO SIGNATURE CERTIFIER <br /> TIIE FOLLOWING: 'I CERTIFY TIIAT n+TIIE PERFORMANCE OF TIIE WOW Fon%-AmN THIS T'EnMfT 19 ISSUED,1 WALL EMPLOY PER9oNS SURJFCT TO WOR"AAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24"OURS IN ADVANCE FOR ALL RFOUIREO INS►EC HONS At("411112051 409-S423. COMPLETE OMWINO AT(OWER ARTA Pf10V1DE0. <br /> OI '� ,� Tllt. rlI�I vl �'�l< l�lS�•f Y' o.l. /1'/3/y p <br /> 919 d X ,t'1' f' <br /> MOT MAN IDr—I-Radel Rn�I�___ 1s�LSLLL_/ <br /> 4. LOCAiroN of NOVAE REWAOE DISPOSAL SYSTEM OR PfKlf`OBED <br /> 1. NAMES OF BTPf.ET8 OR ROADS NEATIE9T TO On BOUNOIKI TIIE PROPERTY. EXPANSION OF BFWAOE DISPOSAL SYRTEMS. <br /> 2. OUTLINE OF THE P'f10PFRTY,GIVING DIMENBIONR AND NORTH 0`1nFC7roN. S, LOCATION OF WELLS WIT/RN RAMS OF ONE HUNDRED FIFTY FT. <br /> ]. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED ON THE PROPERTY On ADJOINING PF10PEnTY. <br /> STMUCTURES,INCLUDING COVERED AREAS GUCCI AS PATIOS,DRIVEWAYS,AND WALKS. <br /> ,I I <br /> I• <br /> ' <br />