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rod 6 <br /> V APPLICATION FOR WELUPUMP 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 /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CBmplAte M Trlplients) <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAGUIN COUNTY FOR A PERMR TO CONSTRUCT AND/OR INSTALL THE WORK DESCWSED.TIIIB APPLICATION IB MADE IN COMLLIANCE VIRT II SAN <br /> JOAMN COUNTY DEVELOPMENT TrNE.CHAPTER 9-11115..3 AND THE STA/MAARRD(S OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB Ap"gEBSNR APNI n <br /> � /0 It K J+P S E X� /�C/_ CITY PARCEL& <br /> OWNFR'S NAME i2- // <br /> ^-I"l ,��//n 3. ADDIIEae . C'Se .ptR✓'®N,�T:aa-,r� I'M <br /> ADDRESS�e4� I / /AM Q Sr E fo3 13�F 40W F ���1 <br /> CONTRACTOR A <br /> ��/ <br /> PVA CONTRACTOR ADDRESS CIJ/. UC♦ PHONEI <br /> TYPE OF MUJPI/MP: ❑ HEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL♦ ❑ OTHER <br /> Y� ❑ INBTALLATIOH ❑ WELL BY EM REPAIR ❑ CMS& ONNECTREPAIR ❑ VAPOR EXTRACTION <br /> �jWELL♦ J <br /> FI. -Ilew❑R..MT N.P. I O� DEPTNPUMPBET-2—o". FIRST WATER I.EVFI /T,9 f O <br /> DYROFPIIMPI ❑ OUTOFSERVIOE WELL ❑ OF.OFNTGMAL WELL♦ ❑ BOIL SdtlNG S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM NA.OF WELL EXCAVATION DA.OF CONOUCTORCAAINO <br /> ❑ UDMCSMI TTOVATE ❑GRAVEL PACKISIZE TYPE OF CAAINO/STEEI/PVC DIA.OF WELL CASINO NL1 <br /> ❑ PUBMMUNICIPAL ❑DRIVEN DEPTH OF GROUT REAL SPECIFICATION <br /> ❑ IMGATIONIAG ❑OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME E <br /> ❑ MONITORING (TROUT SEAL MUTED: 11 Y- [IN. CONCRETE PEDEBTAL By DPUEM❑Y. ❑N. S� <br /> APPROX.DEPTH LOCKING CHEATER BOX/STOVE FIR B <br /> RIOMSM CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE AIEPARED THIS ARICATIGN ANO THAT THE WDTK WILL BE DOME N ACCOIAANCE WITH BAN JOAOUIN COUNTY OPOINANCES,STATE LAWS,AND RULES AHO <br /> REGULATIONS OF THE BAN JOAMN COUNTY. TAME"WRIER OR LICENSED AGENT'S SIGNATURE CEMIFNS THE FOLLOWIHO:'I CERTIFY THAT N THE PEREORMANCE OF THE WORK FOR=D <br /> THIS RFMR 19 ISSUED,I SHALL HOT EMPEOY PERSONS SUBJECT TO WOAXMAN'S COMFFNSAMN LAWS OF CALIFORNIA.' CONTRACTOR'S HAND OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT N TNM PERFORMANCE OF THE MRK FOR VAOCH THIS PERMITT 19 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WDdMSN'S COMMOATION LAWS OF L/ <br /> CIWFORMA.'31 PIICART MUST CALL N HOURA,IN ADVANCE I"ALL IIEOUN[O INAP MM11 AT ISM)4YSIES. COMFLETE DRAWING AT LOWER AREA PROVIDED. <br /> / L� % y^C' <br /> SIPrW X ///'14`,- TIII. �'L'1 /1e� D.. �-�- I � <br /> ROT MN 0.le S IIIW%.I. 'to 1 <br /> 1. NAMES OF STREETS OR POADS NEAREST TO OR BOUNCING THE PROPERTY. �, PANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> LOCATION OF NOVAE SEWAGE ABPOBAL SYSTEM OR AIOIOSED J <br /> 2, OUTLINE OF THE PROPERTY.OPSIN DIMENSIONS AND NORTH DIRECTION, EXPANSIG <br /> 3. DIMENSIONED OUTLTNfe ANO LOCATION OF ALL EXISTSA AND F MSEO A. LOCATION OF WELLS WRMH RADIUS OF ONE HUNDRED FIFTY R. <br /> STRIJCTVRES.INCLUDING COVERED AREAS SUCH AS PATHS.DW VEWAYB,ANO WALKS. ON THE PROPERTY OR ADJOINING PTIOPEATY. <br /> !I <br /> r <br /> PAY m rzw"i <br /> MAY 5 Ifflotow <br /> ISAN JUAOUI'N COUNTY <br /> PUSLIC HEALTH SEHV I <br /> SF!Y)RaNML'N7XCL xF/iLTH DNIS)ON <br /> DEPAR MENT USE ONLY <br /> rT ��APPIIa.Ibn A..aPled Br ONS h.. <br /> G�wllmpWlbn ev D.I. Pump MN v.R BY <br /> O.wmsDen Imn..Ibn By Dm <br /> cPmmaM.: i!-S wHE aU 74- I <br /> ACCOUNTING ORM AIDI FACS <br /> PE CODES FEE INFO d~UHT REMITTEDCNEC ASN RECEIVE"SY DATE PERMITISEAVICE REQUEST NUMBER INVOICE <br /> J 0 `'— 'atwr LB 5/sl9�i 1 /Y <br /> Pub Health Sam.-Enviro.173(1/97) <br />