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A.
<br /> APPLICATION FOR WELUPaMP PERMIT
<br /> SAN JOAQUIN CPUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION ee
<br /> ' P 0 BOX 329, 445 N. SAN JOAOUM ST_ STOCKTON. CA 96701788 S
<br /> (709)4688470 //yam1 _
<br /> NOMREfUN0A1LF PERIMT ELMYf11 Vf�R FROM SA7E ISSUED �� //'� , eAV ct
<br /> Atpl ic.1ion i s here ICae,W[a w T,�htabl
<br /> IND! in e M flcde [b the SM Jua,a,in ,o,rly tar a we,,: eb runs vett Ad/., install the vo, IN Md. Ixls am......an is
<br /> aryl 400e .,in San Joatrdn County Devei opien[ iiHe, C.".sprit 9.•!15.3 am t1r SI.wa'd, of SM Jcpym Cart, PWtic ...tth
<br /> Services, Enviro'lner,.al Health Division
<br /> Jab AddrlSe/or AFRO- 2 N
<br /> ONerrs Max !'P: N"- ry — Avdress _—__-----
<br /> ''
<br /> ____ —�].._L_.— P^m i •'i4 `IJ 1 J -
<br /> Sub Contractor i tC(„ Address_
<br /> --7 , Phone R
<br /> rYof Of WLLM"P• MEM Kit f1 REPLACEMENT WE, 1
<br /> Il MONITORING K[L , LI OTHER
<br /> q DESTRMTIOi 1) OUT-OF SERVICE Kit Il GECPxYSICAL WELL a Et SOIL SHOWING
<br /> 3W IN57ALLATIM 11 WE it SYSTEM REPAIR 17 CAMS-CCNKGt NEPAIY
<br /> Me. 11 Rt VAPOR fYitAC1:04 WELL e
<br /> (TYPE OF PUMP) -- epalr N.A.MPof Pix PUMP SET FT. FIRST WIER LEVEL
<br /> IMIRDFOUSE11 Tied DF LL -- --
<br /> _Wim. CONfTBUCTION fPfC1i1CAT10NS
<br /> 1 WOUSTRIAL (I CITY BOTTOM DIA. OF KLL fwCAVATION— 1 L u1A. OF CONDUCTOR USING
<br /> J2'DOMESTIC/PRIVATE V GRAVEL PAC:/SIZE_ TYPE OF CASING/STEEL/PW r, —_ DIA. Or KLL CASINO
<br /> Il PUBLIC/MJMICIPAL Il DRi VEY DEPTH Cf GROUT SEA',_ �-"!•
<br /> IJ IRP'GATIONJAS ❑ 07NE4 GROUT SEAT INSTALLED Bt —
<br /> _�_ "OIL BRAND NAME
<br /> 11 MONITORING GROUT SEAL PIMPED: A Yes 0 No CONCRETE PEDESTAL BY DRILLER:?E!'Yes EI NP,
<br /> APPROX.O:JTN 2.I< , L
<br /> LOCKING CRE57ER BOy/yTOVE PIPE A,
<br /> PROPOSED COMSTAUCTIONIDMLSIYG METHOD: rRA ROTARYfI AIR NOTARY_- AUGER_ CABLE_ OTHER_ S
<br /> I hereto cert i}y [bt I have P eparM t1 app(Icat:M W tM[ ::e Mork ulll be dare m accordance.1th San Jo
<br /> State Lava, MM Rules and RCUuleffvu of the San Joaquin[oO,tY• Home oNxr or Ii apJ,n CCNnty OrdicNnfn,-_
<br /> certify that in the performance of the Mork for which this permit is issued, 1 hallnete a.y pe siplature cert(lin the following: -1
<br /> CAMs Of hlifOrnfa." Contractor's hiring or sub•co,trecti fot Y persere ALA Kt to WORKMANIS COMPENSATION
<br /> of the Mork for Much this pormIt IN iScmed, 1 shall re si Bruture c<rti Nes the Tel toWIN: 1 certlfy that in the performers.'
<br /> employ oy persons 42)ett to LORI(MAM,S COMPENSATION Laus of Cal l forma." THE APPLICANT
<br /> MUST CALL 74 NOUIIt p ADVANCE f0A ALL REOUTAFD 9ISPFCllOMM AT O41I AM 142). Complete chm.1no at Icaner area provided.
<br /> SitPledX e< CCP)5 - .,n ),
<br /> Title-T WNC-'r Dale 2�-�S
<br /> PLO' PLAY (Draw to State) Sulu_—• To
<br /> 1. Mlles of street. or roads nearest to or broad in, the property. G. LawciM of house aerate disposal 111. or
<br /> 2. Outline of the property. 9ivir,diai<psl M. and North direction. proposed exp rsiM of 9rua4e disposal systema.
<br /> 3. Df.eneioxd aJt UrI MM l0cetfon of alt esi\tfrg 1W proposed 5. Location of Netts Within radius cf 150 ft. o,
<br /> str,a-tures, i"lYliug revered areas smh as pa[ics, drivevays, the property or adjoinin, property.
<br /> and Walks.
<br /> �I
<br /> +441
<br /> II ✓ — -
<br /> I AI_
<br /> U T
<br /> D
<br /> - 1. 5
<br /> AN OA UI C 'N Y
<br /> P BL .
<br /> // DEPARTMENT USE ONLY
<br /> Aiplicaticet Accepted By !! cat.p Z S-'S Are.?LL
<br /> Orate Inspect lun BY / G '. ""nr.--r� Date L/' C'�Ao,p Inspection BYTGIJ 6f, JI Date
<br /> Destivction I.Wti. By Uate Con' ,.:
<br /> AMOliff MO DNIy: AID, .Alf
<br /> PI MOB TEL Rio AMOUNT REMITTED ME" ASH RECEIVED A DATE PERMITSLRYKE S10UESi NOMAER INVOICE
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