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I wr APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION /^ 304 EAST WEBER AVENUE,STOCKTON,CA 95202 fy (209)468-3420 1E011•REFUIPARIE PERWF M PIIRIS I YEA l FROM DATE ISSUElumpS r1.Vo r 1-3 APPI KATION 40/FRE BY MADE TO THE SAN JOAOUIN COUNTY FORA PERSAR 7O CONSTRUCT ANDIOR INSTALL THE WOW DESCNSEO.71115 APPLICATION IS MAD[N COMPLIANCE WRIT SAN JOAOLRN COUNTY DEVELO"AE1NT TITLE.CHAPTER 9.1116.3 AND THE STANDARDS OF SAN JOAOUN COUN'TYnPUMIIC HEALTH BERVICEB,ENVmNMENTAL HEALTH OMSgN. R JOB ADDRESSR1n Arms `r 2,_)j�V.�(JjC • crrYE%vI PARCEL MEE/f/J]ARI[ RI V OWNES NAME,-1 •C11 4'�Yl l.l. �)LL 2G`'--� _ADOME$@ ct Val •l`e�(�f- CONTRACTOR ��l,1'e� _ ADORE SS-`,Z�Ve"l�• U' LICE iNOHEV1lK�Ij Z-�ry N�Q SUB CONTRACTOR ADDRESS LICE PHONE TYPE OF WELLPUMf-- ❑NEW WELL ❑REPLACe WENT WELL ❑MOMTOPNG WELL f ❑OTHER ❑y U IA M.P.NSTALLATIDWELL SYSTEM RA Nw ❑M.P., EM L R - I O rtrrPIE or PIIMPI ovraF-{ERVICEwELI ❑G[oPRvr.�OAL.WELUf `1e eIIGU W1lIiUUI B ❑oeernucymm G�I�I�I I�I It INTENDED Us I TIRE O CON 'A ❑INDUST MAL 13OT4NSOITOM DIA.OF WILL ExCAVAT '.-I:VI�Oli.l l�.•. (1� I'plAl'TJII bQHdjfQEl]gpABINO O ❑DOPASTICWMtl ATF ❑GRAVEL PACKFBRE TYPE OF CA6INORIl1(LMVC DIA.OF WRL CANNG O ❑PUSI.ICMURSCIPAL ❑DNIVEN DEPTH OF GROUT DEAL SPECIFICATION S ❑MMOATIOPIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑MOMTONNO GROUT SEAL PUMPED:❑Yr ❑NA CONCRETE PEDESTAL BY DRUM❑Y- ❑NA 5 AT'PIOX,DMH LOCKSO CHESTER BOIVSTOVE IBPE J PROPOSED CONITRUCTIONlDIRUNO 110111HOO:MUD ROTARY AIR ROTARY AUGER CABLE OTHER II HERBY CERTIFY THAT 111.PIETA.11,11{1F1 111.AND THAT 11 WORK WBL BE GONE N ACCORDANCE WITH{AN JOAOUIf1 COUNTY ORDINANCES.SPATE IUW{.ANO RULES AND TEOULATIONS OF TI/[SAN JOAOUN COUNTY.NOME OWNER On LICENSED AGENT'S SIGNATURE CFJREIES THE FOLLOWNO:'1 CMIFY THAT N THE FERFORSAANC[OF TIE WORK FOR WHICH THS PeMST b ISSUED•1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKARAIR'S COMPBHATION LAWS OF CAI F MAX*CONTRACTOR'S ERRING OR BUSLONTRACTNG MNATUnE CERTPES THE FOLLOWING: 'I CERTIPY THAT N TIE POFORAIANCE OF THE WORK FOR WHICH THS P"WIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOMMAN'{COMPETMATION LAWS OF CALIFORMA.' THE ARUCANT MUST CALL 74"OURS IN ADVANCE PSIS ALL RIOU111®111SKC7110NS AT 17001 ISS-1R7f.COMPLETE OMWINO A7 LOWER AMA PROVIDED. 44..FF x TIN. ROT PIAN W.Fw a 1. 'Is V- 1.NAMES OF fTPEFTI OR ROADS NEATEST TOOK BOUNDING TNF A. LOCATION OF POVSE SEWAGE 010M AL SYSTEM OR NIGTVBED 7.IXRIM Of THE!PROPERTY,OrANG DNA[NMONo ANO NORTH Di, EXPANSION OF SEWAGE DISPOSAL SYBr[MS. G 7.DTMEHM MD OVTLMF{AND LOCA710H OF ALL ExiSfNO AND - S.LOCATION OF WTLLI WTTI-M RAONS OF ONE MINDRED FIFTY FI. STRUCTURES,INCLUOING COVERED AREAS SUCH N PATIOS .AND WALKS. ON THE FI OMM OR ADJONNG PROPERTY. � A. i � • I ... ... 00 a PAYMENT i.. ...... _.... . 1 ..,. •. ... .4 QCT 1 5 1998 .. ISA I 4S1CMtiSTRVIC -ALTA D1VlS )r, vsE ONLY APFII[N1eO ANIgI.A Br o,-k—i,-ST O.I. P—bNPrwtlsn BY DNF --l-In.P«I Sr D''� r Ace.-Two ONLY: ATO/ FAGI �-A M COO[{ PEE INFO AAOVIIT RETATTFO NECK!CASH AlCEVEO NY DAT[ PEPP0STMENRC[REGUEIT NUMBER INVOICE 11 " s o`er 0J 7a zr. " LPub NBBith Sol •Envlro.173(1/97)