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APPLICATION FOR WELLIPUMP PERMIT <br /> \/SAN JOADUIN COUNTY PUBLIC HEALTH SERYL PA'wTMEM71' <br /> ENVIRONMENTAL HEALTH DIVISION F-,rMl„F"TV <br /> P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (2091409-3420 NOV 12 1998 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ..SIN UL1UN.� <br /> (CmapIS18 he TPiIBeetel -'ETH SERVJ— <br /> APPLICATION INNER BY MADE TO THE BAN JOAQUIN COUNEY FOR A PERMIT TO CONSTRUCT ANDAIR INSTALL THE WORK DESCRIBED.TPR§"X/ [IL TRCIS IAIMIIFIVkTpQMpIJANCE WRIT SAN <br /> "AMIN COUNTY DEVELOMENf TILE, /C <br /> CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOINUCOUNTY PUBLIC HEALTH SERVICES,FNVOWNUFFEAL HEALTH DIVISION. <br /> .roe ADDRESIMMIAP or 736'_7 F. q//l0o.S9 d core SAla ckf .er PARCEL e2E/AFNF <br /> owNu•e HAMS- Mu 6J-iF ifTndriStr.fn.A Pio Ae-.F./L:e S Ap 09 .A4ge,' os ZdPHONE. PHONE F y6lo-o L66 <br /> CONTRACTOR_ ri- o (03 LCCLI TLcNIS LVtC ADDRESS Z:�-q L L V'E'r 'F <br /> _ � 7 PHONE F� TL4-3 <br /> Oct Owe CONTRACTOR ADRESS 'E1366 <br /> PHONEq 9 i F <br /> TYPE OF WEL_VPUMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORIND WELL F ❑ OTHER <br /> ❑ !INSTALLATION ❑WELL SYSTEM REPAIR ❑ C11092-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLS <br /> ❑Nwr❑REPJr N.I. DEPTHPUMPSET_FT. FIRST WATER LEVEL O•CALvWLib' <br /> RVPL OF RIMPI <br /> ❑ OVT-0E-eERVICE WELL ❑ OEOPIIYBICAL WELL B IS SOIL BORING 5 BMJ <br /> ❑DESTRUCTION: C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION STOP CAUUNS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING to <br /> Cl DOMESTICATIVATE ❑GRAVEL PACK/RDE TYPE OF CASINO/STEEVPVC DIA.OF WELL CASINO B <br /> ❑ PL BLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION B <br /> r❑r--11 IIM/RRIGATION/AG 13-6TMER �dtwDLQ GROUT SEAL INSTALLED BY CRIME BRAND NAME E <br /> AVRIOX.OEPTM IO �""�ONlTOnIM GROUT SEAL PUMPED- ❑YY 0 N CONCRETEPEDESTALBYDRILLER:❑. ❑l% S <br /> LOCKING CHESTER PDX/e1OVE RPE / w B� <br /> PROPOSED COHS111VCRONSNIIWNB METHOD: MUD ROTARY AIR BOTANY AUGER CABLE OTHE 1412 ALioe/ <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCAITON AND THAT THE W01K WILL BE DONE IN ACCORDANCE WITH SAN MAOUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REAVlAT10NS OF THE SAN"AWN COVNTV. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES ilE FOLLOWING: CERTIFY THAT IN THE REREORMANCE OF TIE WOW FOR WHICH <br /> THIS PERMIT 19 ISSUED,1 SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB.CONTRACTIM SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT RJ THE PERFORMANCE OF THE WOR(TOR WHICH THIS PERMIT IB ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF� <br /> CALIfORNIAAAlA1\\\..��.\\�7iiiN����MMNMlEE AtR. 1IC ANT T A Igllllt 1 NCE FOR ALL REOUMfD IMSFECTON�SIIAT EOSI 1ESSJAtt. CpOMP�L.E�TEy/DRAWING AT LOWER AREA RKIVIDE . <br /> So—,X _ I TRH. U L�-(- I LS L,7L.1 V1 1 <br /> PLOT FLAR IMF 1.SOr.I%.I. 'IS <br /> 1. NAMES OF STREETS OR ROAOS NEAREST TO OR BOUNDING THE PROPITI Y. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMISED!. OVILINE OF THE NK)PERTY,OILING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF REWAOE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OURINES AND LOCATION OF ALL EXISTING AND PROPOREp S. LOCATION OF WELLS WITHIN MOIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PRDPERTY OR ADJOINING PROPERLY. <br /> ,� 1 <br /> DEPARTMENT UBE ONLY <br /> APPIIc.R.n A..PaM ey <br /> D.1s ArY <br /> a'.m ImP..Ren Br 1 <br /> T CA D.1. V I Pump MEPYG.n By DW <br /> Dwlnalwn IrnPxllan or <br /> D.1 <br /> �� / // I . <br /> .m 1 1L <br /> Cms..: 11 11�A(A (AIA eA Ari�C ,&PTI 4tp }n MIA AJ,AA�a.s.. d e-p+1�16 <br /> ACCOUNTING ONLY: AIDS FACE o <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKIMASH RECEIVED BY BATF PERMITISERVICE REQUEST NUMBER INVOICE <br /> b oo bl 3S It I r <br /> C <br /> r <br /> Pub.Health Serv.-ERdTD.173(3196) -- -- _ ------ <br />