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APPLICATION FOR WELL/PUMP PERMIT <br /> a SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> OEC p 8 1998 ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOC}CTON, CA 95202 <br /> v, r (209) 468-3420 UU <br /> QiVISIJP: NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICamplaLS In TIIpREaNI <br /> APRICATION 19 HERE BY MACE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANTIOR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MACE IN COMRIANCE VATH SAN <br /> JOAQUIN COUNTY DEVELOMEENT TITLE.CHAPTER 9-1115.3 AND THE NTANDARD9 OF 9AN JOAOUIN COUNTY PURLO HEALTH SERVICES.ENVIRONMENTAL HEALTH OMSIOW <br /> JOB AOOMSSMR'/A,�.. A I! c V ' CITY C.S Tc C IS i n N �I /! /PARCEL 91ZEIARU <br /> ONMER'9 NAMEFF��•�1,I LE IJ. AU Tr [9- 'Rd IG�A ARKgC ADORRN 2)61 Cn •-dt-j C&6 r)&j2. PEIONEI <br /> CONTRACTOR AJuAnc?D Ct `ovIA-Ip'IEL,IA I IAC ADDRESS �Jqp$ ({J' W,�r••'I 7Uc/ G22 <br /> GUB CONTRACTOR AOOREnB IICI NIONf F <br /> w�i Mw-L ❑ OTHER <br /> TYPE OF WELL/PUMP; '91H <br /> qOOOFFF NEW WELL ❑ NFPLACEMENT WELL �FLL MONHOWNO V/ELL I <br /> .1❑``INSTALLATION ❑ WELL SYSTEM REPAIR CROnnLONNECT REPAIR 1 ❑ VAMA EXTRACTION WELL I J <br /> ❑N.n❑P.e.1r H P. DEPTH PUMP SFT—FT- FIRST WATER LEVEL?IE-)5 ALC= O <br /> OYTV OF PUMPI —�—�� <br /> ❑ OUTOFBEPVICE wELL ❑ GEOPHYSICAL WELL/ ❑ SORE BOmNO B <br /> ❑DESTRUCTIONS <br /> INTENDED Uzi TYPE OF WELL CONRRUCIPON SPECIFICATIONS A <br /> ❑ iNWSTmLI ❑OPEN BOTTOM lL /J�] DIA.OF WELL EXCAVATION fl(� £�j DIA.OF CONOVCTOR CASINO ^� D <br /> ElOOMESTIC i VATE ���'I({GRAVEL PACKRRZE J TYPF OF CABINGMTEEIJPVC /�' V DIA.OF'NELL CASINO Z^ l,It O <br /> ❑ PUSLICAIUNICNAL lJ DAVFN DEPTH OF SCOUT SEAL r, L��fYI�LAL '�O ,L�E CI iT/V SPECIFICATKIN_� B <br /> �q❑l I.OATIONIAO ❑OTHER GROUT SFAL WIFTALLED sYY I NG IIY)Y I,l`TNDO GROUT a" NAME NAMEf C RT���ICC,n o E <br /> �1 MONITORING 2 / GROW SEAL MMEEO' 1�Yr ❑Ns �ck i.Il�CONCl!RLEETE PEDESTAL BY DRJLLERjy Yr Cl. 5 <br /> /AyPP10X.OEPEN JC LOC'KRNI CHESTER ROX/STO , —13I X ' \ 5 <br /> PROPOSED CONSTRVCTONIDISWMO MSTNODT MUD ROTARY AIR ROTARY AUGER CASLE OTHER <br /> I HE�9Y CERTIFY THAT I HAVE FHEPARM THIS AFRJCATION AND THAT THE MAN,WILL BE DONE M ACCORDANCE WITH SAN.81AWIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REOUTATMNS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT M THE E4WORMIIHCE OF TILE WON(FOR WHICH <br /> TMS RRMIT IS ISSUED.I NHALL NOT EM0.0Y MASONS"ACT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HRtlNO OR SUB{ONTRACTING SIONATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE VARA(FOR YMICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORIWAN'a COMPENSATION LAWS OF <br /> CALIFORNIA.' TW APRICAW MUST CALL ZA HOURS IN ADVANCE FOR ALL REOURINO SPR'TNINS AT CVNH BSSJM". COMRETE ORAW'INO AT LOWER AREA RIOVIDED. <br /> 919-1 X THLII •l+ l:?C'O C'I Ji ow. r2.'��-Y! <br /> ROT RAN m....1.B.N.1 N..1. I- <br /> 1. NAMES OF STREETS OR ROAD RAREST TO OR ROLN DI THE PI OPERTY. I. LOCATION OF MOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE RbPERTY.DMIA DIMENSIONS ANO NORTH OBECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> ]. dM,NNON,D OWUNNFE ANO LOCAMN OF ALL EXISTMO ANO PROFONFO E. LOCATION OF WELLa WUMN MMUa OF ONE HUNpED FIFTY FT, <br /> STm1CT1JIEF.NCLUdNO COVETED AREAS SUCH AS PATIOS.DNVEWAYS.AND WALKII. ON THE PROPERTY OR AOJOIHRIO PRbRE11TY. <br /> PAI <br /> DEPARTMENT USE ONLY <br /> APPlbtlbn Aue.PIFd BY D.b � ' �'��Nr� <br /> Rrwn Irwpxlbn BY <br /> ON. RmP 1—.1—BY DS1S <br /> D,.1„c,bn I,.P.e1w,. D•1• <br /> �S <br /> c....m <br /> ACCOUNTING ONLYt A10I FACT <br /> PE COOEE FEE INFO AMOUNT REMITTED CHECKIMASN I RECEIVED NY DATE PDMIT/NERNCE REQUEST NUMBER INVOICE <br />