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APPLICATION FOR WELUPUMP PERMIT COPY <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> ICamp4ts In TrIpREmI <br /> AF ICATION 1911ERE BY MADE TO THE SAN JOAOUM COUNTY FOR A PERMIT TO CONSTRUCT ANDgR INSTALL THE WORK DESCw9ED.THIS AF ICATION I9 MADE IN COMPVANCE WRIT SAN <br /> JOAOUINCOUNTY DEVELGRA�EM TCHAPTERITLE,CHAP'EER 8-11115.7 AND THE STAANDARDDSF OF SAN JOAOUIN COUNTY PIBLIO HEALTH SEF V 1!R,ENVIRONMENTAL HEALTH DMSION. <br /> JCB AODR / <br /> SSMA APNI 15 <br /> \0 n IT r�i QyU AA-A-A,UF� CRv 5�- - EAQ T'c IBJ PARCEL SIZEIAMI <br /> /� n (� (� /I'2{ I R.HEl Zo 9-993-13. 3 <br /> DvnFERs NAME l�(]E Rt)1Ati� A1IOPEe8 (.�. k7Cl�X "7J3\!) ( <br /> CONTRACTOR AlvAAP�F0 Gez %jMnAA'e/I'�RI Z1c . AOOFIEB.7D0S N . ;VLKZnWAYMl 227 PIONE120g. 4p7•/c%b <br /> SUn CONTRACTOR qADOPESS ucl PHONE I <br /> ^IPF OF WELUPUMP. IP�NEW WELL ❑ PERACEMEM WELL �MONROMNO WELL I MIA/-S ❑ OTHER <br /> 10 I-NNBi ALLATNIN ❑ WELL SYSTEM REPNR ❑ CROSSCONNECT REPAIR ❑ VAPOR E%TRACTgN WELL I I <br /> ❑Nwv❑N.BW H.P. DEPTH PIMP AFT-FT. FIRST WATER LEVELr /S•' f` 0 <br /> TYPE OF P1MP1 <br /> ❑ OVTOFBERVICE WELL ❑ AEORIV 6ICAL WELL I ❑ fAll BOWNO S <br /> u DESTRUCTION! <br /> IMT ENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .L A <br /> ❑ :NOUSTRAL ❑OPEN BOTTOM DIA.OF WELL EECAVAnON (�/t IA, DIA.OF CONDUCTOR CASIN�OJ K)/R p <br /> ❑ DOMCSTICA'InVATE ❑GRAVEL PACKMIZE TYPE OF CASINGMTEFIJR'O r ((' (T �ffG ORA.OF WELL CASINO L 1 EIC H 0 <br /> ❑ PUFI MUNICNAL ❑ORrvEN DEPTH OF GROUT SEAL 6 R A OE T. 'l�o�o1T DJ`SPECIFICATION_ E C D F <br /> ,J IRPoOA-mN/AO ❑OTHER GROUT SEAL INSTALLED BY 1 IR Ih 11- FYIZ TOO D GROUT BRAND NAME FJ IFFrA f <br /> ff MCHN-rOWNO /}�C OPOUi SEAL PUMMO0 ❑Y- KN. / CONCRETE PEDESTAL SY DRILLER:yJ,Y- ❑Ne 5 <br /> APPID;.OFITN �J�I L75 G LOCKIRID CHESTER 80A/SFOVE FIFE `.0 r�AD.WF/I &x ' ` s <br /> P10POSFD COMETa1JCnOM/dOWNO METHOD: MUD ROTARY AIR ROTAl1Y AUGER CABLE OTHER <br /> I HERBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE W DRY WR.L BE OONE N ACCORDANCE YATTTH SAN.pAOUIN COUNTY OFOINANCES,STATE LAWS.AND RILES AND <br /> RFOULATIONS OF THE BAN MA01M COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CES IES THE FOLLO\MMO: 'I CFRYSY THAT M THE PERFOWANct OF TIRE WOFK FDA WHICH <br /> 1N19 PEwATT 181SBUED.I SHALL HOT EMPLOY PERSONS"ACT TO WORKMAN'S COMMFHSA1MN"M OF CALFOFEAA.' CONTRACT09.9 HIRING OR S JS ONTRACTIHG M..TUR GESTIDES <br /> THE FOLLOWINO: -I CERFIFY THAT N DIE PERFORMANCE OF THE W OM FOA 4 H THIS PERMIT 1919SUE0.1 I EMPLOY PERSONS SURACT TO WOFFWAM'S COME *AV.M"Vol OF <br /> CALNOPNA�THIS <br /> /APPUCANY MUST CALL 24 HOURS IN ADVANCE FOR ALL RFOUR® R10 <br /> IN1tTNE AT 1ICSIN 4•tlY 23. COMPETE DRAWING AT LOWER AMA PROVIDED. D <br /> S. K / ,�'AA,� I�LAE)LX�y/�� __ no. 'pAa�F CTG, / Dn. 1 Z^L9' 9p <br /> ROT RAN SJ...+l.8..1.1 <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING TNF PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR POPOSED <br /> S. 0,YUHE OF THE P1 HBI GDNo,dMENBSCHS AHD NORTH DIRECTION. E PA N OF SEWAGE DISMISAL SYSTEMS. <br /> O. OSMENSICHED OUTIINEB AMC LOCATION OF ALL E.[ISTMO AND RSUPSY ED S. LOCATION OF WELLS WD-4M RADIUS OF pR RAMIFIED FIFTY FT. <br /> DEPARTMENT USE ONLY <br /> APP1N.Sen AP. 'W 8, <br /> D.M lmpslbn er O.I. _ _ Pvn.lmesoen er D.R. <br /> vn <br /> v..R,vI«,1rwPSHm e. ,p �.s <br /> GCS .la <br /> ACCDUNTMG ONLY: AIDS FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CMCKIMASH HEOTSVFD■Y DATE PETMITUdWCE REOUEST NLILIIER INVOICE <br /> I <br /> ?vD �ewh Se, -cnYIRG. ' !1:971 <br />