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(c <br /> V <br /> APPLICATION FOR WELLIPUMP PERMIT &4 �1 .n. <br /> IV;--- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 0 9 1999 <br /> ENVIRONMENTAL HEALTH DIVISION EEB <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 r ,SNL MRNHT1-' <br /> (209) 468-3420 ' ' ,•IN's _ rLP" w <br /> NOX REFUXUABLE PERMIT EXPIRE2 1 YEAR FROM DATE ISSUED <br /> MatRpwh We TripAatel <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCMSE0 T1118 APPLICATION IB MAGE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11115 3 AND THE STAANOAARJDS OF am JOAOUIN COUNTY RMUC MANLY"SERVICES NVIRONMENTAL HEALTH DIVISION <br /> JO8 ADDRESWR APNF Sr C c,J (G► CITY <br /> ?7 S 10�1��//[//jr�� r PARCEL RZE/AP N6 <br /> OWNER'S NAME t ADDRESS_ yJ�/ C/H!�/�'�IJUr _L1 PHONE 0 <br /> uv- <br /> CONTRACTOR.-_- �2G ,[VV l F/C L ADDRESS 2 3(�' I,V�Gr1�INl� UCv_ I E I h Y l <br /> SUS CONTRACTOR E h� ADDRESS ucs PHONE I <br /> T <br /> TYPE Or wELUPSIMP. AHEW Y11ELL ❑ AEPRJLCEMENT WELL ❑ Mowromom WELL/ �F ❑ OTHER <br /> © INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR08S•CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> ❑N.wr D R.P.Ir H P DEPTH PUMP SET FT FIRST WATER LEVEL O <br /> !TYPE OF RNTFPI <br /> ❑ OU7ORSI:INICE WELL ❑ GEOPHYSICAL WELL R ❑ SOUL BORING/� Jn a <br /> ❑DESTRUCTION• A <br /> L <br /> INTVIDED USE TYPI OF WELJ. CDNaTRUCTION SPECIFICATIONS Qf' A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.Of WELL EXCAVATION // DIA OF CONDUCTOR CASINO D <br /> L7 L10MEsmmmvATE ❑GRAVEL PACKIaIm TYPE OF CASINGISTEEL/PVC 2 ORA OF WELL CASINO <br /> CI MOUCIMMOCIPAL ❑OIBVEN Of""OF GROUT SEAL ��l�5�., SPECIFICATION R <br /> ❑ SVSGATIONIAG ❑OTHER GROUT SEAL NSTALIED BY 1'��.C��Y fYt'•1 GROUT BRAND NAME (J}yWj Ivy/ e <br /> o11-MORINO i ORDUT SEAL PUMPED-P.Y. ❑N. 1 CONCRETE PEDESTAL 8Y ORlLLER.❑Yw CIF. s <br /> A � � <br /> APPROX.DITI'M �+ R LOCKING CHESTER BOXISTOVE PIPE L U6 s <br /> RIOPOSm CONBTRUCTTOWDRILLIM METILDO MUD ROTARY AIR ROTARY AUGER- CABLl: OTHER <br /> MVOURATIONG <br /> Hf-"Y CERTIFY THAT 1 HAVE PREPARED TIaO APPLICATION ANO THAT THE WOF K WILL NE N YAMSE DOACCORDANCE SAN JOACUAN COUNTY ORIDIIANCED STATE LAWS AND RULES AND <br /> OF THE SAN JOAQUIN COWRY HOME OWNER OR LICENSED AGENT 8 SIGNATURE CERTIFIED THE FOLLOWING h CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 1S ISSUED I(HALL NOT EMPLOY PERSONS SUR7ECT TO WORIDNAWO COMPENSATION LAWS OF CAUFOMI&- CONTRACTOR'O HIRING OR SUG-CONTRACTNO SIGNATURE CWTIFIE6 <br /> THE FOLLOWING •1 CERTIFY THAT N Tir PERPS,OF THE WORK FOR W FOCH THIS PETWrf IS I08UW I SHALL EMPLOY P{RBONG SUBJECT TO WORISMAWO COMPER"tION LAWS OF <br /> CAUFOWM4m APPUCANT C Irl undmik IN ADVANCIIS FOR ALL Rl"ORID Wll�*CCrtoNO AT 1200141=.Z622 COMPLETE DRAWING AT LOWER AREA PROM <br /> TL <br /> Shad X 117 <br /> TTt1e 1 1.� OMa <br /> I r IJ <br /> PLOT pw*W to Se.Nd S..1._20L-to <br /> I NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING TINE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> I OUTLINE OF TILE PROPERTY GRINS OPAWSIDNG AND NORTH DIRECTION ETPANIION Of SEWAGE ONaPDeAL SYSTEMS <br /> DIMENSIONED ONTERNFB AND LOCATION OF ALL EXISTING AND PR OPOWD S LOCATION OF WELLS WnMN RADIUS of ONE HUMORED FIFTY FT <br /> ITRUCTURES.INCURNHO COVEFlD/YEAS SU0CN AS PATKNL DISVEWAYS,AND WALKS ON THE PROPERTY OR ADJODOM PROPERTY <br /> A"Mool.Aw.Otad EIy DEPARTMENT LIS!ONLY <br /> ONG.A Ir"Pwtlen GF D.No fto IMp.eth" By Dom <br /> D**tnmI*0%hwo.etl.w ev g D.U. <br /> C._.. � �L7 F� C,$ . �- /I AB <br /> �F <br /> ACCOUNTINQ ONLY AID/ FACS <br /> /E CODER FE;INFO AMOUNT REMITTED CHECTL/ICASH RMOVED SY DATE FTRIMIT/STRWCE REQUEST NUMam INVOICE <br /> iso , <br />