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APPLICATION FOR WELLJPUMP 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 /> ! NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TFIpDcIIEI <br /> AFT11CATION 19 LIM BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDAOR INSTALL THE WORK OFSCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WHIR SAN <br /> JOAOUIN COUNTY DEVELO JAWS 1 16.3 AND THE STANDARDS OF SAN JOAOVIN COUNN�'TY/Y MBBLIICC HEEAALTTH SSEERIIVICEES.ENVIRONMENTAL HEALTH DIVISION, <br /> � Jv ./L—lam I //'v PARCEL SQUAINF <br /> JOB ADORE89,OR ARII A/U/� A CITY ,,E �^J / <br /> OWNER'S NAME /"/_ / ADDNEBB S/F�1L'�4j&— //1L ,L �y/1 MONS 1 t vaL�J•(/� <br /> I A <br /> CONTRACTOR AODPf RB 2d2-4(F. `4,d o l I UC/ ��/ a 1NONE I `! <br /> TWO CONTRACTOR ADDRESS LICI RHONE I <br /> TYPE:OF WELLPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-0ONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑Nµ❑R.pm, 11 P. DEPTH NMP SET—FT. FIRST WATER LEVEL___ O <br /> DYPf OF PUMPI <br /> WbEBTnucnoH: U kit <br /> l ❑ OOU70E-SER <br /> VICE WELL DEORIYFICAAL WELL/ ❑ SOIL BOEING,,,yyy , a <br /> 12-IJ ` Hem - PYi y214/& OT*u <br /> INTENDED USE TYPE OF WFLL CONSTRUCTION SPECIFICATIONS _r A <br /> 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 <br /> ❑ DOMERTICTNVATE ❑GRAVEL PACK/LRE TYPE OF CARINGMTEELIPVC DIA.OF WELL CASINO D <br /> ❑ MAIM MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIIATION B <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y.. ON. S <br /> APRIOX,DE➢TN LOCKING CHESTER SOXMOVE RPE S <br /> RIOrolFD CONlTIIIICTIONn)WlLINO METHOD: MVO RIOTARTY AIR IIOTAgY AUOEfl CABLE OTHER 1 <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS AP ATroN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY OPOINANCEO,STATE LAWS,AND RULER AND <br /> SCOLMTION9 OF THE RAN"AWm COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN TIRE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS MAINLY IR ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'!COMPMLATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUOLONTRACTINO SIGNATURE CERTIFIES <br /> TIRE FOLLOWING: -I CEIOIFY THAT m THF PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORIUUMe COMPENSATION LAWS OF (�y <br /> CALIFORNIA.' i1/m//�IyP/1�,1C�/A/L////I ! C Ib IN ADVANCE FOB ALL REQUIRED INl/FFE TKING AT ISL0A11144S-1422./CIOMPLETE GRASPING AT(OWER AREA 1'RbVIDED. \�I <br /> Shred X <br /> '= <br /> " '�'R/A� TG. �/ / ` �/_//C YI Do. L <br /> ROT MAN NI 1.lkw.l B..I. 'to <br /> L NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF MUSE REWAUE dery SAL SYSTEM On PRIOroSED <br /> 2. OUTLINE OF THE RgPERIY,OWING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISTOSAL SYSTEMS. r <br /> T. DIMENME ED OUTLINES AND LOCAMN OF ALL EXISTING AND PROPOSED L. LOCATION OF WELLS WTTMN RANVS OF ONE HUNDRED FIFTY FT. 1 <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,ANO WALKS. ON THE PROPERTY On ADJOINING PROPERTY. �(r <br /> _ lam'• <br /> r <br /> o <br /> 'PAYM EN'S <br /> JUL 1 - 1998 <br /> 'P <br /> SAN JOAQUIN COUN1"Y <br /> PUDLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEAL?"H OIVISI n: <br /> DEPARTNIMT USE ONLY <br /> C T'Aonwl <br /> npo <br /> ne. A..,,. Br OFHF 1 Ary <br /> O..ul Imp«Ibn BY D.1 Imp Imp«tl.n BY D.1. <br /> ` r� <br /> D+IncHl.n Imn«Ibn BY <br /> Cemmvxc <br /> 1 �1 <br /> ACCOUNTING ONLY: AID# FACS 14( 6c' <br /> PE CODE! FEE INFO I AMOUNT REMITTED CHEC (CASH RECDVEO BY DATE PERMITILERVICE REQUEST NUMBER INVOICE <br /> 37 3 p <br /> Pub Hearth Sew,-EDAM 173(1/97) <br />