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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE_S. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST.WEBER AVENUE,STOCKTON,_CA 95202: <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRE?1 YEAR FROM DATE ISSUED:. <br /> • R:ernplete IB Triplketel . <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR APERMIT TO CONSTRUCT AND/OR INRfALL THE WIOHc WSCKBEU.TH12 APPLICATION IB MADE M COMPLIANCE WITH BAN <br /> JOAGUM COUNTY DEVELOPMEEE/NT TITLE,CHAPTER 81118.3 ANO THF BTANDATO9 OF BAN POAQUM COUNTY PUBLIC HEALTH SEAVICER,ENVIRONMENTAL HEALTH OPASMR. <br /> JOB AOOwomRAPNN IL_.0 , e,EALZM K(} CITY q C(� PARCEL SITEJAPNI <br /> o4YNER'B NAME •1'If� �/J. �M �) }y.�. .. .. ADORE68, 9�jJlpl.}e/J�//��jVJ,T�7.�-,y[���Iil(y! PHONE! <br /> CONTRACTOR G&ue'/LY A•.KLLLT✓��-MG AODRE6B,fi7/, s. ICILLGT/Y /LFGLIOF�PHOHE/ , 1 <br /> SOB CONTRACTOR }--•� ADDRESS GCSPHONE <br /> TYPE OF WEUIPVMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MO WHORING WELL a 1❑Tyy OTHER <br /> ❑INSTALLATION ❑WELL eYSTEM REPAIR ❑CROSSCONNECT REPAIR L..1 VAPOR EXTRACTION WELL F J <br /> ❑Na-E3 Rgmr H.P. DEPTH RUMP eET_FY. FIRST WATER LEVEL O <br /> R YPE OF PUMP T7 <br /> C3OUT-Of-DERVICE WELL ClGEOPNYre1CA�L WELL R L3 BOR BOPoN�O 6 <br /> �.OEBTRI/CTMIIh.!!l �/1L � ���/..��//r)� — /•�!V//��/1J`/ ^. ���i'' �rC.L(/�f—� <br /> INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATIONS A <br /> 0 INDUBTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION OIA.OF CONDUCTOR CASINO O <br /> ❑DOMESTICIPTRVATE ❑GRAVEL PACKISIZE TYPE OF CA8INO/STEEIJPVC OIA.OF WELL CAGING b <br /> 0 PUBLUC,UWFRCIPAL ❑DRIVEN DEPTH OFOROUT SEAL SPECUTCATION A <br /> ❑MARGATIONIAG ❑OTNER GROUT SEUL INSTALLED BY GROUT BRAND NAME E <br /> ❑MONITORING GROUP REAL PUMPED:❑Y.a ❑NS CONCI¢TE PEDESTAL BY DRILLEII:❑YM ❑Ne S <br /> APPROX.pr/TM r LOCKING CHESTER BOX/aTOVE PWF s . <br /> PROPOSED CONSTRUCTIONMPIMUNG MEFNOD:MUt1 ROTARY AM ROTARYAUGER CARLE OTHER _ <br /> N <br /> I HEREBY CFRTIIY THAT I HAVE PREPARED THIS ARi1CATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH RAN JOAOUIN COUNTY ORDINANCES.STAT!LAW6.AND RULES AND • F <br /> REGULATIONS OF THE BAN JOAOUM COUNTY.NOIRE OWNER OR LICENSED AGENT'S SIGNATUFE CERTIFIES THE FOLLOW/O:'t CERTIFY THAT IN THE PERsoRMANCE OF THE WORK FOR WHICH <br /> THIS PWwrr IR ISSUED,I SHALL NOi EMP1, PERIGHR SUBJECT TG WORgAAN'S COMPEIIIATKN LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING.09BUS-CONTMCTMG SIGNATURE CFRFW"$ <br /> TRIF wLL '1 1 THAT IN 1 IIFORMA CE OF THE WDNL FOR WHICH THIP PE 16 18sm.1 SHALL EMPLOY PERSONB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORM 1 MUST M TIL'AuvA NCI FOR ALL REQUIRED 1N NS AT 1 14*0-",. DRAWING AT LOWER AREA FM 0. <br /> SIe.ad X TIS. D.la <br /> PLOY MAN ah• Ie SaHH Sam. 'ro <br /> 1,NAMES of STREETS OR ROADS NEAR,EBT TO OR OUNDINO THE PROPERTY, 4. LOCATION OF HOUSE REWAOE VMPOBAL SYSTEM on <br /> PROPOSED '7 <br /> 2.OUTLINE OF THE PROPLRTY,GIVING ORMEHBDNS AND NORTH OOECTIOH. EXPANSION OF SEWAGE OUSPOIAL SYBTEMR, (- <br /> },DRMENBRDNEo o1JILIWF.8 ANO LOCATION OF ALL EXISTING AND REDPOBFD 6.LOCATION OF WELLS WTTWN RAbM@ OF ONE HUNDRED FIFTY FT. N <br /> STRUCTURES.INCLUDING COVERED AREAS BUCK AS PATOI,bWVEWAYB.AND WAIAS. DN THE PROPERTY OR AOJOINRTG PROPERTY. (f) <br /> .. ... .,. <br /> a <br /> Go <br /> ry iL VA CJr� <br /> w_ 1-F0 <br /> Y <br /> .. . Sr. <br /> I <br /> dUL 1 7 1998SAN j <br /> :. . <br /> ...- - .... ENVIRGNMCN EA 7H SERVE <br /> .. ... LHICj <br /> fACTN,Df . <br /> I <br /> ppMTMENf W!ONLY <br /> AFPNMI.R A~.d by <br /> O..�e LrPaellen eT on. P.anp ErP.Pn.�,SY b.w r7 <br /> oamnwllan 1++rPpetHn BY Dm. <br /> �2�1 -Z -7�J �1) aISCaLN� d G <br /> Caw+r <br /> rm o. <br /> ACCOUNTING ONLYt AJOI FAC+ <br /> PE CODER FEE INFO AMOUNT ItMWTTT'D CNfl ASH RECE[VED SY DATE POIAITNSDRVICE REOU"T NMMPAR INVOICE <br /> L <br /> 7 J <br />