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i <br /> APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IGBgM1R RI TrIpIMete) <br /> AFTUCATON IS HERE BYI)AOE TO THE BMJ JOAMR COUNTY FOR A PERMIT TO CONSTRIKT ANOMR INBIALL THE WORN DESCRIBED.TIRE APPLICATION 18 MADE IN COMRIANCE WITH BAN <br /> "AMR COUNTY DEVELOPMENT <br /> .IIB COMMCTOR^/y.-l�JI/U,�Lx" y.�T"ITALEII.SCHAPTER 9-11 <br /> 115.9AND THE STA R)ARDOOF BAN"AWN CO PUBLIC HEALT/H'811WICES.ENNWEMAL HEALTH DM <br /> BNN. �tJOB ADDRESSA R APNF !Jl?� h• TAY I c-�,, KL1. cnY - OL/ LTPARCEL 81ZE/APNIt-j3 <br /> OWNERS NAME vldyz-- a,,: ofdF1 ADOEBB MRF <br /> CONTRALOIADRR. V'}y" e- DIA . ob) 2 ,MwSly 3W-2Z <br /> 2 <br /> ./V USIFJS <br /> II4 -' 181- ADORE.. ME PHONE nif.'&2-S5Lt <br /> TYPEOFYVELLRUMP. ❑ NEW WELT. ❑ mYLACEAIFM WELL ❑ MONITORING WELL F ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBB-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLF J <br /> 11NAY❑P1 H.P. DEPTH PIMP BET fT. FIRST WATER LEVEL O <br /> HYPE OF NMP \AAI <br /> ❑ OVfOENVKEQWELL ❑, -SOL-O�RYRKAI WELL I BOB.BORNG Qi CA, <br /> I T B <br /> �QfSTRUCTION' � II �jV L�U� ' rU/,U,•�v`1 > I , <br /> �����VVVIII I <br /> INTENDED USE jYPE CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRAI ❑OPEN BOTTOM DIA.OF WELL EXCAVATION IL/ _ IYLCN DIA.OFCONOLKTORCASMOWA O <br /> ❑ MMESTICI VATF ❑ORAVEL PACRJBIZE -TYPE OF CAIINO/BTEELNVC DNA.OF WELL CASINO p <br /> ❑ RIBLICMUNICIPAL ..❑fOIBVEN DEPfM OF OROVT.EAI 1✓.r[/ BIECIPCATION R <br /> \L❑7'SIRWOAM/N/AG LLVTHER aV��/,lleo 0100LR REAL INBfAIEID BY CT1lI� OIOW.RANO HAMS 2N/��✓L <br /> AIO�TBWyO aE0 / ,,,LJ n' DIIDUT BEAT PUMPED:1I Yr 0 N 1�� p..CONCRETE PEOEBTK BY DWLLFR:❑YRI Ns S <br /> APPROX.DM" �15 -� 111 IIITT4 ///lllµ.a LOCKING CHESTER BOXAEMM RIME T <br /> 5 <br /> PROPOSED CONSTRMTION/DRLUNG METHOD: MUD ROTARY AIR NOTARY AMERIV\ CABLE OTHER <br /> I HEMBY CERTIFY THAT I HAVE PREPARED THIS AFPUCATION AND THAT THE WOR(WRL BE DONE M ACCORDANCE WITH BM"AMIN COUNTY OROMANCE8.STATE LAWS.AND FIRESAND <br /> REGULATIONS OF TME BAHEOAdIM COUNTY. HOME OWNEROR LICENSED AOENT'8 SIGNATURE CERFIFHB THE FOLLOWING!'I CERTFY THAT IN THE FEREORMAME Of TILE WORK TOR WHICH <br /> THIS PERMIT R ISSUED.111HALL HOT EMPLOY RR80NS SUBJECT TO WORKMAN'S COMININFATION LAWS OF CALIFORNIA.- COMMCTOR'B HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIER <br /> TILE FOLLOWING: -1 CERTIFY THAT M THE PERFORMANCE OF TILE WOR(FOR WHICH THIS MMUT 18 IBBUED.18NALL EMPLOY PRIFONS SUBJECT TO WOROAM'S COMPENSATION LAWS OF <br /> CALIFORNIA.' 11E APPLICANT MV T CALL 24 MOMS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT IINHR 40*4M.]1E.cCOMPLE'TE DRAWING AT LOWER AREA FIND ' (C Ivy <br /> RICH+X TIII. ✓'eO 1I f- <br /> ROT RAN RM.w Ie BON.-B..1. le M` <br /> 1. NAMES OF FTe ORM R AREBT TO OR BOUNpNO TILE FNORRTY. 1. LOCATION OF HOUSE BEWARE dePOBAL BYSTFM OR RTONOSFD �/', <br /> 3. OUTLINE Of THE ETDRRTY,O DMfHBIDNS AND NORTH OIIFCTION. EXPANSION OF BEWARE DISI9BAL SYSTEMS. _^ <br /> 1. DIMENSIONED OUTLINER ANO LOCATION Of ALL EXIBTMO AND FMMI fO S. LOCATION OF WFLLB WITHIN MOAT*OF ONE HUNOfWD FIFTY F,. <br /> STRUCTURES.INCLUDING COVEMO ARAB SUCH M PATO..ORVEWAYS,AND WAU(8. ON THE PIORRTY OR ADJOINING P MRFY. <br /> R� <br /> i I G GEOTECHNICAL`ONLY <br /> S t> <br /> CHEMICAL TESTING <br /> xs mo+�l �Yhq I.ac�Lh'p�-, �n <br /> N'W� <br /> a VeoL (�EOF.iVI_O <br /> MAR 2 2000 <br /> SAN "OUOJ GIAIN:S' <br /> / 2S U 4--.I L.1'�DOU/ti F43. 1117 'I'.TH SFwl FS <br /> 1 Ni IP�pIIN cA <br /> CH OM!,i}b <br /> 9 <br /> orl LAND USE # SPS--` Cf -1(�(p <br /> `�I(J � DfPM�-TM�E1N-T-1LAOSF ONLY��• ��" / �` <br /> m.Nl I...Pe..Hn ey D.I. Pme m.P.OBeI ey D.1. <br /> DnNNw1Le '712 <br /> CHRIS...: O� <br /> ACCOUNTING ONLY: AIDE FAG <br /> PE CODES FEE INFO MOUNT REMITTED ITEC MAIN RECOVER BY DATE PDMHTISDIVICE REOUEST NUMBER INVOICE <br /> S / , <br /> P,b ` Aalth.Sere.-Envlro. 173(1/97) <br />