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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> (Complete M TrIpReStel <br /> AFPLKATjVN IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WONT DESCRIBED.TINS AMICAMN IS MADE IN COMPLIANCE VRID SAN <br /> MAO N/COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY FURM HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. F <br /> JOB AOd1FSsoR Amu 20763 E. Harney Lane CITY 31raw 1r nJ en, rANCEL SU®APNS 87 acres <br /> OVJHER'RNAW Robert Indelicato Awe, 16930 E.. Comstock Rd.Lin , <br /> coNTRACToRPurviance Drillers, Inc, AVDNEBSP.O.Box 64 ,LindeaB 377923FM EB87-3554 <br /> BIN CONTRACTOII ADDRESS (ICI RgNEI <br /> TYRE OF WELLJPUMP, ❑ NEW WEU ❑ My AI:vww WELL ❑ M WONNO vnu S ❑ OTHER <br /> ❑ BJBfALLATM ❑ WELL SYSTEM N:PJUR ❑ CNOS"ONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> Turb )EkN-0 P.,* H.P.40 DEPTHFUMPSE 2-6-0,T. FIRST WATER LEVEL O <br /> NYPE OF PUMP <br /> Cl OVfADFSERVKE WEIt ❑ GEDPIVMCAI WELL E ❑ BOR RONNO B <br /> ❑OFNTRIJCTION <br /> INTENDED USE TYPE OF WEA CONSTRUCTION SPECIFICATIONS A <br /> 11 INDUSTRIAL ❑OPENDOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 <br /> ❑ DOMESTK;A VATS 13 DRAWL PACK/SIZE TYPE OF CASINGRITEEt/PVC DIA OF WELL CASINO O <br /> ❑ PINUCIMUNKR`AL 1:1 DRIVEN DEPTH OF GROUT BEAL SRCIMATION A <br /> ❑ IRIGATIONIAG ❑OTHER GROUT SFAt NSTAMEO BY ONOUT BRAND NAME E <br /> ❑ MOMTONNO SNOUT SEAL FINNED: ❑Y. [IN. CONCRETE PEDESTAL BY ONIIER:❑Y. CIN. S <br /> APPILOX.DEPTH LOCKING CHESTER WXUTOVE PIPE S <br /> PILOROSEO CONSTRUCTIONIONLINO METHOD: MUD NOTARY AIR NOTARY AUGER CASLE OTHER <br /> I HEREBY CERT"THAT I HAW PREPARED THIS APPLICATION AND THAT THE WOM YOM BE VOLAE m ACCOMANOE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE BAN"AWN COUNTY. HOME OWNER OR MENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT W THE PERORIMANOE OF THE WORK FOR W D <br /> TWO PERMIT IS ISSUED.1 MIALL HOT EMFIVY PERSONS"ACT TO WORKMAN'S COMRfMSAOUM LAWS OF CALIFORNIA- CONTRACTOR'9 HIRING OR W"OHTRACTNG SIONATURE CERTIFIES <br /> T '1 CfRTI If PERORMANOE OF THE WOR(FOR WHICH TMS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WCAMAN'S COMPENSATION(AWS OF <br /> C ORMA.- AR ID T VST LL 3A HOURS IN ADVANCI FOR ALL REOMRED INSMIDONS AT 1]881 Atli.]]. COMPETE ORAVAM AT LOWER ARTA IAOVIDEM <br /> RIE ClGGLvzy� Tm.Corporate Secretary D.IF 3/29/99 <br /> PLOT MM ON.Ie 9e0.1 BP-I. Ie <br /> L NAMES OF BERETS OR MADS NEAREST TO OR ROUNDING THE RIOIERrv. 4. LOCATION OF MUSE BFWAOE OUPVSAL SYSTEM OR PROPOSED f, <br /> Z. OUTLINE OF TIFF FTIOPERTY,DIVING DIMENSIONS AND NORTH WRECIMN. EXPANSION OF BEWARE DISPOSAL SYSTEMS. <br /> ]. RMfNM WO OUTLIW9 AND LOCATION OF ALL EXWT.AND PROPOSED S. IOCAMN OF vmus WOH1N MONS OF OM NuMmu rulN <br /> STRUCTURES,KICIUDINO COVERED ANUS SUCH AS rATIOS,DRIVEWAYS.ANO WALXR ON THE P10FERTY OR MJONAM PROPERTY. <br /> aelarn�ic v3 <br /> VAYV1f ENI <br /> MW 2 91999 <br /> SAN JOAQUIN OOVNfY <br /> ^ ' pUBUC HEALTH SEITVICE9 <br /> T' ENVIRONMENTAL HEALTH DNIRI/' <br /> QjA <br /> ` E.MTMEM V NLY TJ Z1 <br /> nPPPabn A.SNIId ley ' ON. •� <br /> roeu.I,wP..Ilen RD D.L. F.Re NSpMSen By <br /> n.H.��n.e Irne.cee^nr GHA / <br /> commo-A. <br /> ACCOUNTING ONLY: AIRF FACT <br /> R CODES FEE INFO AMOUNT REMITTED CHECK /CASH RECVV D BY DATE PONRT/SERVICE REQUEST NUMBER INVOICE <br /> OS-0 SD <br /> Puh Health SON.-Envirc 173 (1/97) <br />