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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> l f�� 304 EAST WEBER AVENUE, STOCKTON, CA 95202 0 � � <br /> lJ (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR <br /> FROM DATE ISSUED Sk <br /> ICempM1F M TTIpRattl <br /> APPLICATION IB HERE BY M TO HnOAWBN O <br /> COUNTY J <br /> FOR A PERMIT TO CONSTRUCT ANDg6INBTALL THE WOR(DESCRIBED.TARS M'PLIC ION IB MADE IN COMPLIANCE WITH SAN <br /> JOAOVIN COUNTY DEVELOPM NT T"lF.CHARTER B-1 16. D �E STANDARDS OF BAN MAOUM COUNTY PUBLIC HEALTH SERVICES,ENVIRON ENTAL HEALTH OMBION. <br /> SLS C.orvw-r �' 1� 5�\e Wtil <br /> Joe ACDREBBgR APNI 0.WA� r�r\ \'yPir' Vj)/lL.� cm PARCEL eaE/APHR <br /> OWNER-BNAMEc(;JFrV 0 L/kflAYvp D MDRIER <br /> CONTRACTOR `L 0.� Ori L.LS� AOCNEBS I S�S I I.'VtiJ)T IQI IICI. RET R R "HE F <br /> BURCOWMCTOR S "ImmeB W UCO "NEI7r 7..., <br /> TYPEOF WELUPUMP: 11NEW WELL ❑ Mr ACEWHY WELL ❑ MONITORING WELL I OTHER CiCJ <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CFKNH- ONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑N.❑R1.PNr Mr. DEPTH PIMP SET—IM. FIRST WATER LEVEL O <br /> RYR OF PIMPI <br /> ❑ DVT-0E-SERVICE WELL ❑ GEORIVBICU WELL I ❑ ROA eORNO B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF CONSTMMINaM SPECIFIC TIONS A <br /> ❑ INOVRTRAL ❑ORN BOTTOM CIA,OF WELL EXCAVATION CIA.OFCONOVCTORCARIN <br /> O / D <br /> ❑ MEBWR <br /> TICVATE GRAVEL PACKRIZE TVR OF CABINGIBTfEI/rVC DIA.OFWELLCAMNO D <br /> ❑ MHUMMUNICIPAI ❑DRIVEN DEPTH OF GROUT SEAL /. SPECIFICATION A <br /> ❑ IMOATIONIAG ❑OTHER GROUT REAL INSTALLED BY DiQ-I ORDM BRAND NAME �1 E <br /> MONITORING `^ GROWSEAL PIMPED: ❑Yr ON. CONCRETEPEDESTALSYDRILLER:RI Y. ON. a <br /> APPROX.DEPTH 'J LOCKING CHESTER BO OVE E I <br /> MOMSM CONBTRIUC"ONRORIUNG MFTHOIH MUD RDTARIY AIR ROTARY JUCEACABLE—OTHER <br /> I HMNY CERTIFY THAT I HAVE PREPARED THIS APPLJCATION AHO THAT THE WOR,WILL BE DONE m ACCORDANCE WITH BAN"AWN COUNTY ORDINANCES.STATE LAWS.AND RULES ANO <br /> MOLMTgNR OF TIIE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S BIONATURE CERTMIEB THE FOLLOWSI(:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> T IRS RMI"IB IRRUEO,I SMALL NOT EMPLOY PERSONS"ACT TO WORKMAN'S COMPENSATION LAWS OF CAUFOPRA.- CONfRACMR'S NIF RG OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE KOY PERSONS SUBJECT TO <br /> THE <br /> C UFORRVAY.'I� A CERTA "BI ALL f MD IN ADVANCE PM ALL REm M IINOM MMS AT I[oBI /NSf.HAT 4 KRIFORMANCE OF THE WOM FOR WINCH VMS"MIT 19 19BUID.I MALL MCOMPLETEE CvvW'1N0 LAT LOWER AREA PHOVB)M .AHOM LAWS OR <br /> ^Ser3�0A\�D.1. <br /> FLOT MAN Vow.Ie e.N.l ea.l. 1-• 'b '1 ^ <br /> � <br /> I. NAMES Or STRFTS OR MADE NEAREST TO O BOUNCING THE PROMRTY. —E A. LOCATION OF NOVSE SEWAGE d9POBAL SYSTEM OR Pg108E0 <br /> E. OMUNE OF TNS MRIM,OIVBIG MIMENSIO1,18 ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DMfNBIOMD OUTLINES ANO LOCATION OF ALL EXHITINO AND MMSED t. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNORM FIFTY FT. <br /> STRUCTUTIER,INCWDINO COVERED AREAS MUCH All PATIUB,DRVEWAYI,AND WALKS. ON THE PROPERTY OR ADJOINMO PROPERTY. <br /> PAYMENT <br /> .... /l/ES RECD VE6 <br /> �✓ MAR ,1 <br /> YCN COON <br /> . .. .. LTH'S <br /> N C <br /> NTgt FI�� I <br /> ... IVI IOv, <br /> boa <br /> P° <br /> Y ..... <br /> I_.� ` 1Il� DAMTMOVT USE ONLY <br /> A.Plle.lbn A«yRed BY q�' �/�/" t \( L'A' <br /> W�-�/ OH. 1 l <br /> omu h.P«Olen eY Dn. 2 P.er Imr«Gen <br /> by O.I. <br /> M'nuwllen Irwn«Rbn Br Oit. <br /> cenman. <br /> 9016 <br /> CUD <br /> ACCOUNTING ONLY: 1 MDI VI ACI <br /> M CODES FEE INFO AMOUNT REMITTED CIECK❑CASH RECEIVED SY DATE REIEHITRFRVICE REOUEtiN 891 INVOICE <br /> 5Z Low 1 3 11 505 <br /> Pub Health Sew.-Enviro.173(1197) <br />