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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 00- 9 � NON-AEFUNaABIE PERMIT EXPIR#9 1 YEAR FROM DATE ISSUED <br /> ICgmpI4tl in TR��4TII <br /> API'LfCA{ION I8 HEAf BY MADE 10 TIIE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCAIRED.Tl tin APPLICATION fS MADE IN COMPLIANCE WIIII SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITTtl.CHAPTER 0-1116.3 AND TIIE BTANGAMS Of BAN AOUIN COUNTY PUBIfC IfEA 111 SERVICES.ENVIRONMENTAL IIEA4.111 DIVISION. <br /> JOg ADOhEB@A7R APN/ � C CITY PA .EL BIZFJAF'Hff <br /> I <br /> r-- <br /> ONRTER'i NAME 1 ADORES$ roNE Y <br /> COH1MCrOR 7 ADORES$ uc Rm2a velI110NE 1 C <br /> BU$CONTRACTOR Abbr;EG8 LICd 1'1 LONE I <br /> I <br /> TYPE OF WELUPUMP; ❑ NEW WELL © REPLACEMENT WELL ❑ MOFIFTOR ING WELL i ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYS 7EPA REPAIR ❑ CROBg-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> i C` <br /> ❑New�R.PN� II.P._� RfPIl11`UMP BET i. FIRaT WATER LEVEL/.0e) I <br /> a YPE OF PUMPI -w- <br /> ❑ bLR1.OF-SERVICE WELL ❑ GEOPIIVSICAI WELL/ © Som RofUNO B <br /> 1 ❑bEBTRUcl10N: (''ll <br /> ti <br /> ! INTENDED UIE T YPE OF wta CONSTRUCNON iPECIFICATtONS <br /> -1 A <br /> IJ INDUSTRIAL ❑OPEN BOTTOM CIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> 0f DOMfGtIC/AYVATE ❑GRAVEL PACKIdf2E TYPE Of C ASINOI81 Efl/PVC DIA.OF WELL CASINO _ a <br /> ❑ PUBLICIMUNICIPAL ❑bAIVEN DEPT II OF OROUt$SAL SPECIFICATION R <br /> IRNOATION/Aa ❑OTHER ()ROUT ttALTNSTALLED BY GROUT BRAND NAME E ' <br /> MOIAtOIVNG r DRUUT HEAL PUMPED: ❑YM ❑Ne COIICKETE PEDESTAL BY DRILLt R:❑Y.. to. S <br /> r <br /> APPROX.UTPTII _ _ .S LOCKING cIfEBTER BOxrerovE MI'E <br /> ."R()PORED CON#TRUC 110MlpF4LLINO METHOD; MUD ROTARY A!R ROTARY AUGER CABLE tlTHFR <br /> iltq*BY CERTIFY 711AT I I4AVE PTIEPAF%ED THIS APPLICATION AND THAT 711E WORK WILL BE DONE IN ACCORDANCE WItN BAN JOAQUIN COUNTY ORUlNANCES,STATE LAWS,AND RULEB AFI; <br /> REOULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S 0143HAt URE CERTIFIES THE FOLLOWING.'I CERTIFY THAT tN THE PERFORMANCE OF 111E WORK FOR WIiICN 11�/f 1 <br /> Ting PERMIT IS ISSUED,1$IIALL NOT EMPLOY PERSON$SUBJECT TO WORKMAN'#COMPENSATION LAWS OF CALIFORNIA.' CONFRACTOR'6 IBRp10 OR 4UB-CONThAcma SIGNATURE CERTITIE�' J <br /> flit TOLLOWING: 'I CEITTIFY 7lIAT IN TI! I'vto ICE OF 111E WOFK FOR WItICH 11109 PERMIT Ig ISSUED.I/HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM IATION ULW@ OFA/// <br /> HALIFOAMA,�1 PPLICANT MVIT C Zi I IN AOVANC#FOR ALL REGUIRED INSPWTTIONS AT 12041 4","27. COMMETE DRAWING AT LOWER AREA PROVIDED. <br /> HOT IRAN FID—to ga.111 B..I. Is <br /> i. NAMES OF 11TREETS CA ROAD@ I EAAEBT To OR BOUNDING THE FT701lERTY. 4. LOCATION OF/roUSE REWAOE DISPOM gYSTEMOR RYIOPovty <br /> !. OU111NE OF TIIE PDOPfRTY,OMM70 DIMENSION$AND NOMH DIRECTION. EXPANSION OF#EWADE DlgpgdAi SYSTEMS. <br /> 2. DIMENSIONED OVTUNF.d ANO LOCATION OF ALL EXISTMIG AND P"OPOSED g, LOCATION OF WEWAEjj E IRP CALRADSY OF-MS.31UNOlIEO FlFri FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS, ON THE PADPERFY OR ADJOINOM-PTToPERTY, <br /> .. � <br /> ICRA' <br /> I <br /> i <br /> DEC -1 1998Ail <br /> . <br /> PU N1l HEAL�JFI SUINICI.5 <br /> .. .. Ervvll`....nnr.N1:a�11FAI:rII <br /> OEIMTMEIIT UltE GAILY J <br /> 14,11-49—Aeawt.e gY . <br /> dw i,.p—j$-,By By <br /> D.e. tem Ing <br />�• i. ..lpjq gNLY7 <br /> AIDS <br /> FACT <br /> Nell <br /> TEE INFO AMOUNT REM111ED - CIIECK 7CA611 RECOVEQ BY DATE PERMI118ETIVICE REQUEST NUMBER INVOICE <br /> t - L17 <br /> � ylh t -r u yr' <br />