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6 • <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 J <br /> (209) 468-3420 <br /> -J NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER <br /> v 3 - ICompletD In TrIpDeEtBI <br /> APPLICATION IB HERE By MADE PIE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDNPI INSTALL THE WOR(DESCRIBED.THIS APLICATION 19 MADE IN COMPLIANCE WITH BAN <br /> APPLICATION 19 IJM By MADIFJOAQUIN COUNTY DEVELOPAEN'�IE,CHAPTER 81115.3 AND THE STANUAMB OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AMMSSMR AMID �TG3S nJ /N /.D��/nh'S/ � Cm,� �(� PARCEL 917VAM, <br /> OWNER'S NAME •,�(( � _y l.-(/CCe--(�-A—y�Cil'��ADDRESS �fL�/L7�(,_� U'y/`�`/ // <br /> CONTRACtOR1TC�l//-1/IC �I� tJl/FGf.I AODr1EBB_ '{'UVIJ IU��✓{V \S�� Ucf 06 PHONEI 7 /U ICJ <br /> NUB CONTRACTOR ADDIIEBB�/VL�TZY�1 T-- PIC/ MIONE <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL X.I MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CMB"GNNECT REPAIR ❑ VAPOR EXTRACTION WELL! J <br /> V YPE OF RIMPI <br /> ❑N. FiSSN H.P. OEM"PUMP BET R. FIRST WRER LEVEL 0 <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL! y�.J BOIL BONNO S <br /> ❑OESTRUCTroN: <br /> INTENDED USE TYPE OF WELL COWAIRM710M SPECIFICATIONS /^� A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION gl/ DIA.OF CONDUCTOR CASINO �'Ar 0 <br /> ❑ DOMEBTIOANUVATE GRAVEL PACK/BRE TYPE OF CASINOISTEE C— DIA.OF WELL CASINO (!(A D <br /> ❑ MRMWUNICIPAL 130MVEN �`^n�/1 DEPTHOFGROUTSEAL ` n SPECIFICATION <br /> �❑1IIMOATIONIAG LFOTNER �j,V l/U`!/�,/ OROUT SEAL INSTALLED BY ✓I V'[� GMUT DRANO <br /> 1J MOMTONNO / I GROUT SEAL PUMPEO: ❑V—-pia.— CONCRETE PEDESTAL SV DRILLER:❑yr [IN. S <br /> ^ <br /> APPROX.nSM" ) LOCKING CHESTER DOXIBTOVE PPE S <br /> PROPOSED CONITRUCTIONNWMINO METHOD: MUD ROTARY AIR NOTARY AMER v CABLE <br /> I NERESV CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE MW WILL BE DONE M ACCORDANCE WITH CAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> MOUTATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR MENDED AGENT'S SIGNATURE CERTIFIES THE MROVO NGI'I CERTIFY THAT IN THE MWORMANCE OF THE MW FOR WHICH <br /> THIS PERMIT IB ISSUED.I BIULL NOT EMPLOY PERSoND"ACT TO WORKMAN'S COMPIDNCATION LAWS OF CALFOIMA.- CONTRACTOR'S MAINO OR CU"ONTMCTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CER I"THAT M THE PERFORMANCE OF THE WOW(FOR WHICH THIS PLMIIT 18 HISUEU,1 SHALL EMPLOY PERSONS SUBJECT TO WMIGION'S COMMI ATION IAW8 OF <br /> CALIFORNIA.-�THIF APPLICANT MUST CALL 31 HOW IN ADVANCE FOR ALL REQUIRED INBFlC1/TJT(11�FRI AT IMI 41N Iif, COMPLETE DRAWING AT LOWER AREAy/ OVID D. <br /> et'r X <br /> ROT RAN Bb.«le ee.l.l Be.l. 'tele TVT <br /> 1. NAMES OF I TMUS OR ROADS WAWBT TO OR BOUNDING THE RIOISRTY. 4. LOCATION OF INJURE SEWAGE DISMBAL SYSTEM on P110POBED <br /> E. OWUNE OF THE MKITTY,GIVING DIMENSIONS AND WW"DIRECTION. EXPANSION OF#MADE DISPOSAL BYBTEMO. <br /> S. DBAENCIONED OUTLINED AND LOCATION OF ALL EXURERE,AND pROM,M D. LOCATION OF WELLB WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> BTRUCTUMS,MLUDINO COVEMD AREAS SUCH AD PATIOS,DWVEWAYD,ANO WALK, ON THE Pr MRTY OR AOJOINITIO PROR/ffY. <br /> .. ..... `/u / .. _.. ., <br /> i <br /> DEPARTMENT UC!ONLY <br /> Applle.Ibn AaaTlee <br /> By <br /> Oreul Impmlbn Br // n D.I. Pmp Imnmtlen ay Om <br /> On.InBUen Imneclbn av (tit.�N.L'G S < Y h Jo J <br /> Cemmmb: <br /> ACCOUNTING ONLY: AIDS FAC# <br /> PE CODES FEE INFO AMOUNT MMITTEO CHECK#NACH RECEIVED BY DATE PEAMITICERVICE REQUEST NUMBER INVOICE <br /> 0 7S <br /> Pub Health Serv.-Enviro.173(1/97) <br />