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cq7144 �-t`(�i <br /> APPLICATION FOR WELLIPUMP PERMIT In <br /> *SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICIT <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (2091 4883420 <br /> MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICompM1E ID TrIpD1:B1K) <br /> APPLICATION M HERE RY MADE TO THE BAN JOACHIM COUNTY FOR A PERMIT TO CONSTRUCT MOTOR INSTALL THE WOW(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WT 11 SAN <br /> JOAUUIN COUNTY DEVELOPM JNLE.CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICE@.ENVIRONMENTAL HEALTH DMIMN. �[�, <br /> JOB ADDREA&O ATM# L CITY J11Q'Y PARCEL BRE/APR/ ////��//�A*J����� AJ'TE./ <br /> OWNER'S NAME I ADORES gm PHONE 1_16/�]/Y W'dn_r_ <br /> CONTMCTORjym ADDRESS UCI PHONE Iffib stZ�K-z <br /> Sue CONTRACTOR ADDRESS jLP��T_�. � PHONE 14m <br /> CEMEW <br /> ER <br /> TYPE OF WELI/PUMP: a <br /> INSTALLATION ❑ WELL BY8 EM REPAIR ❑ CR08&CONN CT MPAIR ❑ VAIPOR EXTMCTIOYVJEU.I J <br /> ❑New❑Rwelr H.P. DEPTH PUMP SET-19'. FIRST WATER LEVEL O <br /> (TYPE OF PUMPI <br /> ❑ OUT-OF BERVICE WELL ❑ GEOPHYSICAL WELL# BOR NOTING @ <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECINCATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISRE TYPE OF CASINGISTEELPVC DIA.OF WELL CASINO D <br /> ❑ PuBUCJMUNICIPAL ❑DRIVEN DEPTH OF STOUT SEAL SPECIFICATION R <br /> ❑ IRRIGATIOWAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING Y GROUTSEALPUMPED:❑Yw ON. CONCRETEPEDESTALBYORLLER:❑Yw ❑N. S <br /> APPROX.DEPTH ,3 LOCKING CHESTER BOXMOVE PIPE ,E( `. .// 3 <br /> moMSM CONSTRUCTIONIDIBWNO METHOD: MUD ROTARY AIR NOTARY AUGER CABLE <br /> 1"IMBV CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWN,ANO RULES AND <br /> REGULATIONS OF THE SAN JOAUUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PE @ UM,1 @HALL MOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'@ HIRING OR SUB-0ONTMCTINO SIGNATURE CERTIFIES <br /> THE LLOWING: 1 CERTIFY THAT N THVF EERM11 ANC, F THE WORK FOR WHICH THIS PERMIT IB IBAUM.1 SHALL EMPLOY PERSON@ SUBJECT To WORKMAN'S COMPENSATION LAWS OF <br /> CALL PENIA.' THE PPUCANT MU O 2411 S 1 DVANCE FOR ALL REOUMD INSPECTIONS AT LhHH 4@@J42S. COMPLETE DMWING AT LOWER AREA PROVIDED. <br /> AIa�eS X Tllle � D.I. L 2-- <br /> PLOT PIAN ID'.w le S.a.1 Bed. 'm <br /> 1. NAMES OF STREETS OR ROADS NE TO OR BOUNDING THE PROPERTY. 4. LOCATION OF MOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,OM MENSION@ AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PRGPOSM S. LOCATION OF WELLS WITHIN MINUS OF ONE HUNDRED FIFTY R. <br /> STRUCTURES.INCLUDING COVERED ASEAN SUCH AS PATIOS.DRIVEWAYS.AND WAIXS. ON THE PROPERTY On ADJOINING PROPERTY. <br /> sa9�-R CNu FSC.N skl <br /> 11�° »6 cc <br /> Os (o Fe Lae <br /> i <br /> i <br /> 0 100' <br /> i <br /> DEPARTMENT USE ONLY <br /> AO0111en AeaplM BY <br /> anvl 1_1_11^By Dae Pumv Imneellen BY D.I. <br /> Owrr,clbn I...Pxrlm BY DM. <br /> Camme.R.: <br /> ACCOUNTING ONLY: AID# TACO <br /> PE CODES FEE INFO AMOUNT REMI TED CHECKOMA@N RECEIVED AY DATE PORMITISERVICE REQUEST NUMBER INVOICE <br /> aV7,66 2 to a - 4 <br /> 20 <br /> Pub.Health Sew.-Enviro.173(3/96) <br />