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j��- 32vv-U� • • <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION MAY 14 1999 <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER <br /> I <br /> APPLICATION IB HERE BY MADE TO THE RAN JOADUIN COUNTY FOR A PERMS TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED.TIPS APPUCATXIN IB MADE IN COMPLIANCE Wrtll SAN <br /> JOAQUIN COUNTY DEVELOPMENT TOLE.CHCAPTER 9-1115.3 ANO THE STANDARDS OF BAN"AMIN COUNTYPUBLICHHEEAALLTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRISSIOR APHI�J� S. CEnr r-F , ST CRY S 'K.14 1 v <br /> p PARCEL BIZNAPNI <br /> OWNER'S NAME� {nF.LC.1.1CYF�S t-I;`LECCT'RI C, Gp ADDRESS 1J$�S. G�t-7 Tsf- ST PHONE I709 -13j 2z <br /> CONTRACTOR C 4 2-AA RILA- Co rJ -I l�y�[�-fDQ+�i I Ll�l IEII lbw A'DvW" Lzo�p o pb <br /> ADOBESB OAM F> jb EGA 94WI ucF733633 RIONEF 5LD 251-24 <br /> SVS CONTRACTOR ADDRESS LIC, PHONE <br /> YPE <br /> TOF WELLMIMP: ❑ NEW WELL ❑ REFLACEMENT WELL �1'�j/W'MONRORNG WELL F ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CWSS.CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F i <br /> PE <br /> 11 N.El FWP ' H.P. DEPTH PIMP SET FT. FIRST WATER LEVEL 0 <br /> �R-YyOF PVMPI <br /> OMYSICAt WELL <br /> IL <br /> y T—INCrRVICE W L lr• ❑ OE F W-LD ON <br /> ("A\,V - GI FY�W <br /> OESTRUCiroN: 5 T9'E r'10 nJI-ITI <br /> INTENDED WE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> IJ INDUSTRIAL OPEN BOTTOM DHA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTM/ VATE ❑GRAVEL PACKMIZE TYPE OF CARINGMTEEINVC DIA.OF WELL CASINO O <br /> ❑ PUTIM MUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL SITCIFMATION R <br /> ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME F <br /> ❑ MOMPONNO GROUT SEAL PUMPED: [1Y. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yw ❑Ne 5 <br /> APPROX.OMH LOCKING CHESTER BOX/STOVE RPE 5 <br /> MOMSED CONSTRUCTION/ORLUNO METHOD: MVD ROTARY AIR ROTMY AUGER CASLE OTHER <br /> I HER:SY CERTIFY THAT I IIAVE RRPARED THIS APR/CATION AND THAT THE WOq(WILL BE DONE N ACCORDANCE WITH BAN JOAQUIN COUNTY OR MANCES.STATE LAWS,AND RULES AND <br /> RFOULATIONS OF THE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTNIES THE FOLLOWING:'1 CERTIFY THAT N THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IR ISSUED,I SIIALL NOT EMPLOY PERSONS SUBJECT TO WORXMAN'S COMPENSATION LAWS OF CAUFORMA.- CONTRACTOR'S HIMM OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE I CERTIFY THAT N THE PERFORMANCE OF THE WOR(FOR Wl11CH THIS FERMR IR ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORXMAN'S COMPENSATION LAWS OF <br /> CALLFO A.' INE APPDClk MVBi CALL 2S HOW IN ADVANCE FOR ALL REOUMFD�IINNBRCMNNS BATT OHNN/Rtl0i/ln.�COMPLETE dUWING AT LOWER ARTA PROVIDED. <br /> elp+d X_ TIHP f bUfXl R- 1PTI�IPC" j� <br /> T Dm <br /> PLOT MN R".le a W.l ea.l. Re <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE MBPOBAL SYSTEM OR ROMSEO <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH MSECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND WMMD B. LOCATION OF WELLR <br /> S WNIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> INCLUDING CLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALRs. ON THE PROPERTY OR AGJONRq RgPERTY. <br /> COUR_C .5T r <br /> W', _ IE1ini-I� TJ V� <br /> � 66' <br /> Mw =6 <br />