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APPLICATION FOR WELLIPUMP PERMIT D�X63 8 <br /> �► SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIes <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O, BOX 388 304 EAST WEBER AVENUE, STOCKTON. CA 95MI-M <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ' !P <br /> (Cempl•n In TripBttISl <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNrY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> "AMIN COUNTY DEVELOPMEW TIRE,CHAPTER 8-1116.3 AND THE 8T ID DB OF BAN JOAQUIN COUNTY P LIC HEALTH SERVICES,ENMMNMEWAL HEALTH DIVISION. <br /> JOB ADDRESSMR AMI CTI <br /> PARCEL SIZE/AMI <br /> OWNER'S NAME <br /> ADORE PHONE I <br /> CONTRACTOR ADDRESS _/L�///•� <br /> RHONE I/'/ / _\\Ai-Y <br /> SUB CONTRACTOR ADDRESS TTnnr�-+-O <br /> IICI PHONE/ <br /> TYPE OF MI. M ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ IN LLATION ❑ WELL SYSTEM REPAIR ❑ CR08SLONNE�/�yfT�(Jq q ❑ VAPOR EXTRACTION WELL/ <br /> E�New❑Repelr H.P. DEPTH PUMP BET FIRST WATER LEVEL <br /> iE OF PUMPI O I _ <br /> ❑ OW.or.mn IC WELL ❑ GEOPHYSICAL WELLS ElBOIL BORING S <br /> 11 DESTRUCTION /�' �L . <br /> INTFNOEOTYPf OF WELL CON•TflUCT10N 6TlPECIFlGTION• <br /> A11-2 <br /> �iTT ��URIAL OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO <br /> 11LODMESTICB VATS El GRAVEL PACK/SIZED <br /> tYPE Of CASINO/STEEI/PVC GIA.OF WELL CASINO O <br /> ❑ PU9RCIMUNICIPAL ❑DOWN DEPTH OF OIOW SEAL SPECIFICATION F_ <br /> ❑ IRRIGATIONIAG ❑OTHER GLOW ILEAL INSTALLED BY BMW BRAND NAME B <br /> ElMOMTORINO GROUT SEAL PUMPED: [I Y. ❑Ns CONCRAE PEDESTAL BY DRILLER:❑Yr ❑Ile S <br /> APPROX.DEFTH LOCKMO CHERTER BOX/STOVE PIPE <br /> PIIOPo6ED CONg111JCTIONIDRLUMO METHOD; MVD ROTARY AIR ROTARY AUGER CARIE OTHER 5 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED TOB APPUCATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCE8,STATE LAWS.AND RULES AND ��LL•. <br /> nEOLAATONB OF THE BAN"AMIN COUNTY, HOME OWNER 09 RCENBEO AOEW'B SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WNICII <br /> THIS PERMIT IS ISSUED,IBI/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION HAWS OF CALIFORNIA: CONTRACTOR'S HIRING OR BUB-COWMCTINO SIGNATURE CERTlilE6 <br /> THE FOLLOWING: •1 CERTIFY THAT IN TII RFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,18HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPI NIATION LAWS OF <br /> CAUFORM T PPUCANT VST CA 4 W •IN ADVANCE FOR ALL FMMRED IFIS N•N•.,AATT f 1tOI 18r-Ntt, COMPLETE DRAWING AT LOWER AREA PgVipE/D1. C <br /> 81'-1 X <br /> —C I Oxa <br /> PLO N Ideal le Sete)Beel. •le <br /> I. NAM 8 OF STREETS OR ROADS NEAREST TO On BONNER THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PIOIO6ED <br /> Z. OUTLINE OF THE PROPERTY,GIVINe DIMENSIONS AND NORTH DIRECTION. EXPANKON OF SEWAGE DIBWSAL SYSTEMS. <br /> ]. DIMENSIONED OHTUNEt AND LOCATION OF ALL EXISTING AND PROPOSED 8. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDoto FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> I <br /> t <br /> �6C�C'ie2� <br /> < 1�(I- <br /> i� <br /> IL� �Dio� <br /> PAYMENT <br /> 1044�3 f MAY - 1 1998SAN CONIY; <br /> - PUSUC HEA llf SER <br /> TVICES <br /> ENVIRONMENTAL HEALTH 1) ISION <br /> DEFARTM TWE omy `/>> c <br /> n.vlbelbn A.vrlM SY ✓ -�------ - Dx. 5 � a 181 A— 2- <br /> By BY <br /> D.1. <br /> cemmNxe: <br /> ACCOUNT RG ONLY: AID/ FAC# <br /> Ff COGEt iEE INFO AMOUNT REMITTED HECK ASII RECEIVED BY GATE PFRnSTRV1VICE REGUEW NUMBER HNVGICE <br /> D 3 ff485 LZ 511 8 Y <br /> Pub.Health Serv.-Enviro, 173(3/96) <br />