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` APPLICATION FOR WELLIPUMP PERMIT <br /> i/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> 12091 466.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICampMtB M TrIpRIBtal <br /> APPLICATION IS HERE BY MADE TO THE BAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DEMRIRED.T1418 APPLICATION IS MADE IN COMPLIANCE M11 BAN <br /> "AWN COUMY OEVELOFMEM TMU,1CCHAPTER 81116..3 AND THE STANOARVS OF BAN JOAWIN COUNTY MBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.bf�((.0 <br /> JOB AMMOmmon MtHr L V, ( 1a C J Coq 11 i'h� Gab cl , ,S me-krall PARCEL SIZVAPNI <br /> OWNER'S NAME LI1V D/LLES/ V ck W n1 <br /> ADRESS r <br /> mow I <br /> CONTRACTOR / VfQ� ADREBe P•019n)C PHONE NE <br /> "COMPACTOR ADDRESS 55Dj*jVcR0( 11ti ZJIqQJ s" <br /> RIONE Friab•3/3 3��V <br /> TYPE OF WEUJFPUM . WELL ❑ REPLACEMENT WELL ❑ MONDORINO WELL IIK W Z ❑ OTHER <br /> ❑ mSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> (TYPE OF MMPI ElN.11 R.P.F N.P. DEPTH PUMP SET ". FIRST WATER LEVEL O <br /> ❑ OW-OF SERVICE WELL ❑ OEOMYSICAL WELL I ❑ SOX BOWNO R <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRMIION FPECIFICATIONB a I A <br /> ❑ INDUSTRIAL F❑N�AOPEN BOTTOM II ,/� VIA.OF M/ELL EXCAVATION OAF,/ DIA.OF CONTRACTOR CASINO O <br /> ❑ MMESTICR IVATE ICIGRAVEL PACKMn PJ�ST41 TYPE OF CARINOIBTEEVPVC NC- DIA.OF WELL CASINO �Il 0 <br /> ❑ MBtICRJUNICIPAL ❑DRIVEN DEPTH OF GROUT MAL 3 SPECIFICATION R <br /> ❑ IRMGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY MBR. IDI I L GROW BRAND NAME q E <br /> MONITOnINO T GROW REALRIMMM ❑Y.. IOIRe CONCRETE PEDESTAL BY DRILLER:10 YM ❑Ne 5 <br /> APPROX.DEPTH 1>u/ LOCKING CHESTER BOXWOW PIPE VOWIf�O Y s <br /> PROPOSPO CONSTIIUCTIONm10lUN0 METHOD. MUD ROTARY AIR ROTARY AMER _CABLE OTHER <br /> 1 HEREBY CERTIFY TRAT I IMVE PREPARED THIS ATgICATMN AND THAT THE"W WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOEW'S SIGNATURE OERTHIER THE FOLLDMNO:'I CERTIFY THAT M THE PERFORMANCE OF TILE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WOMIMAN'B COMPENSATION UWB OF CALNORNIA.- CONTRACTOR'S HIRAM OR MB CONTRACTINO SIGNATURE CERTIFIER <br /> THE FOU.0"NO: -1 CERTIFY THAT IN TILE PERFORMANCE OF THE MW FOR NMICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAHFORMA.///��TW��APPLICANT <br /> //MUST CALL 24 MOLLIS IN ADVANCE FOR ALL AFGUIRED INSMMNB AT IZOSI 441411JS33, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> EIOn�X �TW710•(/f,y THI. fiS LeZ (J'♦✓Qloe K 7— D.I. 23-be' <br /> ROT PLAN(Ow.to Bex.l Bexe C •I. O <br /> 1. NAMES OF BTIIEETS OR ROADS NEAREST TO OR BOMMO THE PDOFERTY. I. LOCATION OF HOUSE SEWAGE DISPOSAL SYSFEM OR P oro SED <br /> t. OUTLINE OF THE PROPERTY,OMW DIMENSIONS AND NORTH DIM..CTION. EXPANSION OF SEWAGE DISMI AL SYBTEMS. <br /> 3. DIMENSIONED OWLmEB AND LOCATION OF ALL EXISTING AND PMPOSED B. LOCATION OF WELLS WITHIN RADIUR OF ONE IIUNnRED HFTY FT. <br /> STRUCTUIIEB,INCLUDING COVERED AREAS SUCH AB PATIOS,OPVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING F ROMM. <br /> Ab 7L Q <br /> j <br /> S <br /> �t ca a I IL <br /> Commy 6A 81Ua <br /> DEPARTMENT USE ONLY 17 <br /> AWP .11en Avee -BY /��RC� /-jam I--- Yf—•2' Cl Ula A,. <br /> 0'.x Iw.albn Br Dxe RPP Impmllen By 0NR <br /> DwOtmlbn II.P lP By <br /> L Dxa <br /> C.-".: �Srk o-� �'d�-tL'hB✓1 ��°�c.�W.LoA.�.d' Pern4at� fa�fl�f.3 lh AP S-iC� <br /> ACCOUNTING ONLY: NDE FACS <br /> P[COD" FEEINFO AMOUNT REMITTED CHECKIMA IN RECEIVED BY DATE PEMRTIIEIRVICE REOUEIT NUMBEII INVOICE <br /> �°I � IL24• of I2� g <br /> Pub.Health Serv.-Enviro.173(3/96) <br />