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7 APPLICATION FOR WELLIPUMP PERMIT r('", <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ra BOX 388.304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)468.3420 <br /> 1109•REFURDARLE FEAWT EXPIRES I YEA#FROM DATE ISSUED <br /> ICBIAFwis In TIIpIIenE( <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQLRN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TWO APPLICATION If MADE n:COMPLIANCE WITH SA <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COVjRY,PURUC HEALTH SERVICES,FNVIRONLEENEAL HEALTH DIVISION. <br /> JOA AODAEBBAR APNF• CRYJ11�i1 PAICK SIZfJ\PTJ4 <br /> OWNEA'S NAME ADOPESS .1 /•" ./ l i-•f ii A(.Y.'y7�LONE 4aaL.t •ZL <br /> CONTRACTOn /fir-%��.1�1< O., 1 l!I L-I. AOORESf% uD&� naHe <br /> SUB CONTRACTOR ADDRESS tic# PHONE <br /> TYPE Of VYj1JJP1M P• ❑NEW WELL L LWIACEMENT WELL Q MONITORING WELL F ❑OTHER— <br /> ❑OWTAUATION ❑WELL SYSTEM REPAIR R cAOSS.CONNECT REPAIR ❑VAPOR EJLTRACTFON W2LL <br /> O N—13P.p4II M.I. DEPTH PUMP BET FT. FRET WATER LEVEL <br /> TTYPB MMPI <br /> ❑OUTOFSERVICE WELL ❑GEOPHYSICAL WELLr 4 ❑ BUIL SOMNO <br /> I ��fSTl1UGTION:.�+/,.` r.`,v. T`.. f_Z. y�;�_;_•�'h __ _ _ <br /> INTENDED USC TTPE OF WELL CONATRUCTJON SPECIFN:ATIONS <br /> ❑IINDVSTRIAL ❑OPEN iso TOM DIA.OF WELL EXCAVATION SI <br /> DIA.Of CONDUCTOR C ANO <br /> f3-DCMf NTICJRYVATE -©6MVEL PACKM-Zt TYPE Of CASINOfSTEFLBNC 1" J- Of WELL CASINO <br /> ❑PUSLFCIE.WMCIPAL I❑�1 DRIVEN DEPTH OF 43MUT SEAL SPECIFICATION <br /> 13MI <br /> IOATONfAG DOTH GMV7 <br /> EAL NSTA1LFDSYGROUT BRAND NAME <br /> ❑MONITORING ROUT SEAL FIJMEO-BL- TT,NCONCRETEMOFSTAL SiYtrMYAJ,lER ^J��Y-1:--a�y. <br /> . <br /> APITDX.O4PTH LOCKING CHESTEN BOXIVTOVE PPE <br /> MICPDSED CONBTRUCTIGNMRBLUNO METHOD: MUD RDTARY_>_AOI ROTARY AUGER- CABLE OTHER <br /> I HIMESY CERTIFY THAT I HAVE PRFPAAEO THIN APPLICATION AMD THAT TNF WORK WILL NE DONE IN ACCOMANCE WITH BAN JOAQUIN COUNTY ORDINANCES.RATE LAWS,AND RULE4 A <br /> REOLRATION4 OF THE SAN JOAOUW COUNTY. NOME OWNER OR IICENBEO AGENT'S WGNATUR CEKIIFIES THE FOLLOMNO:'I CERTIFY THAT IN THE PERFORMANCE OP THE LWGAK FOR%411 <br /> THJS PERANT 14 I441JED.I SHALL NOT EMPLOY PERSONS SUBJECT TO W'ORKMAN'4 COMFENSATTON LAWS OF CALIFORNIA.'CONTRACTOR'S WRpN0 OR■U"ONTR4CTI IG MONATURE CERTIF <br /> THE FOLLO`MNG: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TMS PERMIT 18 ISSUED,I MALL EMPLOY PERSONS SUBJECT TD WORXMAN'S COAAMOATTON LAWN <br /> CAUFMNIA' THE ATFOCANT MUST CALL 34 HOURS 1N ADVANCE FOR.UL MQUIIM IM\PSCTION8AT MON 4604423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> IG <br /> SIp-4 X 1. I !•f;'!i a: .n T . ' ) I 1%{v. D-1-5Z <br /> PLOT PLAN ID—I.Sc..I S..IF _• 'I <br /> 1. NAMES OF STREJ'TS ON ROADS NEAREST TO OR BOUNDING THE POPFRTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYMM OR PROPOSED <br /> 3. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE 04SMOAL SYSTEMS. <br /> 3. DIMENSONEO OUILIWG AND LOCATION OF ALL tMWrV4O AND PfOPO4E0 S.LOCATION GF WELLS WTTNN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.LNCLUOP40 COVERED AREAS SUCH AS PATIOS,DMMVFWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PIOPEFTY. <br /> 1;60. . . ;I •{, ',Ei x•�I .. <br /> LIZ.S-•.r SIA.^ �I�.'/4'f•.. <br /> Jal� nQp <br /> cl,i 41" <br /> DETAATMEM UO ONLY rI 1({ 11 1NI1� <br /> ADPINNIon A.WtFd Ay �..tll�L1L—{//J�/SjC�Ay��(�( � ��- 11fr <br /> GrsIA IrnP.eLl.n <br /> fly_ L1.1.-]-�,L.J 1�.el'an+p 1-0-1en BY _� ON. <br /> D..INael.n b.x..rin br �• `�`ti,J f WI. 6, to <br /> �L II[COIINTINO GNLY: ALO/ FACS <br /> F <br /> PS CODES fTE INFO /MOUNT RAXATTLD CNSCX AAH RlCfl VED AY DATE POM714DMCE REQUEST NLPA4BI INVOIIE <br /> �sbz- <br />